Artroscopia do Ombro

Question 1

Quais são as radiografias solicitadas para avaliar instabilidade do ombro em pacientes jovens? E em pacientes de meia idade?

Answer 1

Young adults with symptoms of instability should have true anteroposterior, Westpoint, and Stryker notch views, as well as an anteroposterior view with the shoulder in internal rotation to evaluate for changes to the glenoid and humeral head. Middle-aged and older patients should have outlet, axillary lateral, and true antero-posterior views.

Question 2

Quais são as contra-indicações para realização da artroscopia do ombro?

Answer 2

Contra-indications to shoulder arthroscopy include local skin conditions, remote infections that might spread to the joint, and increased medical risks.

Question 3

Quais são as vantagens do decúbito lateral para artroscopia?

Answer 3

The lateral decubitus position probably is more commonly used because of better access to the posterior shoulder and the relative ease and safety of positioning.

Question 4

Quais são os benefícios do posicionamento em cadeira de praia para artroscopia do ombro?

Answer 4

The beneits of the “beach chair” position are ease in orientation and surgical manipulation in the subacromial space and ease in conversion to an open surgical procedure. They noted faster and easier patient positioning, reduced risk of neurapraxia because traction was not used, less distortion of intraarticular capsular anatomy, improved mobility of the patient’s arm, and easier conversion to open procedures because repositioning and repreparation were not required.

Question 5

Quais complicações descritas para o posicionamento em cadeira de praia para artroscopia?

Answer 5

Complications of stroke and death have been reported from hypotensive episodes in the “beach chair” position; blood pressure at the brachium is lower than that in the cerebrum and potentially significantly lower if carotid artery disease is present.

Question 6

Quais as vantagens do decúbito lateral com tilt de 20 a 30o posteriormente para a artroscopia?

Answer 6

Gross and Fitzgibbons modified this straight lateral decubitus position by tilting the patient 20 to 30 degrees posteriorly, which places the glenoid surface parallel to the floor. They reported three advantages of this modification: (l) less traction, decreasing the risk of neurapraxia of the brachial plexus; (2) accentuation of tears of the glenoid labrum because they are pulled away from their beds instead of in line with them; and (3) improved arthroscopic access to the inferior third of the glenoid labrum and capsule.

Question 7

Quanto de tração deve ser aplicado ao membro superior para artroscopia do ombro em decúbito lateral?

Answer 7

10 to 13 lb of traction is applied.

Question 8

Qual o posicionamento do membro superior para artroscopia do ombro?

Answer 8

Klein et al. studied the strain on the brachial plexus with varying degrees of abduction and flexion. They concluded that two positions (45 degrees of forward flexion with 90 degrees of abduction and 45 degrees of forward flexion with 0 degrees of abduction) provided maximal visibility with minimal strain on the brachial plexus.

Question 9

Qual a taxa de complicação pós artroscopia do ombro em decúbito lateral?

Answer 9

Complications after shoulder arthroscopy have been reported to be between 23% and 30%, most caused by neurapraxia after excessive arm traction.

Question 10

Qual a posição do braço para artroscopia do espaço subacromial e para artroscopia da articulação acromioclavicular?

Answer 10

The arm position for arthroscopy of the subacromial space and acromioclavicular joint is slightly diferent. The arm is brought down to 20 to 45 degrees of abduction and 0 degrees of flexion. This position permits mild inferior subluxation of the humeral head, opening up the subacromial space.

Question 11

Quais são as desvantagens do posicionamento em cadeira de praia para artroscopia do ombro?

Answer 11

The disadvantage of this technique is dificulty in working from posterior portals and decreased cerebral perfusion when hypotensive anesthesia is induced. As mentioned earlier, complications of stroke and death may occur from hypotensive episodes in the “beach chair” position.

Question 12

Quais são as três técnicas para controle do sangramento intra-articular na artroscopia do ombro?

Answer 12

The first technique is to use an arthroscopy pump for inflow, maintaining a constant fluid low and pressure of 60 to 70 mm Hg. A second measure is to add 1 mL of 1 : 1000 epinephrine to each 3000mL bag of irrigant, if the patient has a stable pressure and no cardiac contraindications. The final technique, and perhaps the most efective, is to use hypotensive anesthesia, with a systolic blood pressure of 90 to 100 mm Hg. A systolic-to-pump pressure gradient of approximately 30 mm Hg should be maintained when possible.

Question 13

No procedimento artroscópico do ombro, qual o aumento da pressão intra-articular e quanto tempo após o término do procedimento a pressão intra-articular retorna aos seus valores basais?

Answer 13

Ogilvie-Harris and Boynton, in a report of 25 arthroscopic shoulder procedures (20 acromioplasties), reported that pressures increased from a baseline of 12 to 120 mm Hg, but within 4 minutes of termination of the procedure the pressures returned to normal.

Question 14

Qual tipo de anestesia deve ser evitada em pacientes idosos posicionados em cadeira de praia para artroscopia do ombro?

Answer 14

In older patients, particularly with “beach chair” positioning, hypotensive anesthesia may not be advisable.

Question 15

Qual é o ganho de peso de fluido líquido extravasado durante a artroscopia do ombro?

Answer 15

Lo and Burkhart evaluated 53 patients immediately after shoulder arthroscopy and found an average fluid weight gain of 8.7 lb.

Question 16

Qual o portal que passa mais próximo a uma estrutura neurovascular?

Answer 16

The portal that passes closest to a neurovascular structure is the low anterior portal approximately 1 cm from the cephalic vein.

Question 17

Qual estrutura neurologica está em risco na colocação dos portais anterior, lateral e posterior?

Answer 17

Awareness of the axillary nerve is important in portal placement anteriorly, posteriorly, and laterally.

Question 18

A que distância se localiza o nervo supraescapular e a artéria circunflexa da escápula do portal posterior?

Answer 18

Posteriorly, the suprascapular nerve and circumflex scapular artery are approximately 2 cm from the portal site.

Question 19

Quais são os portais para acessar o espaço glenoumeral, espaço subacromial e articulação acromioclavicular?

Answer 19

The glenohumeral joint portals can be made posteriorly, superiorly, and anteriorly; the subacromial joint portals are placed anteriorly, pos- teriorly, and laterally; and the acromioclavicular joint can be approached from the subacromial space anteriorly or posteriorly.

Question 20

Quais radiografias devem ser solicitadas para avaliar lesões fisárias em atletas jovens?

Answer 20

In an adolescent athlete, with dominant-side pain during sports requiring overhead motion, anteroposterior views with the shoulder in internal and external rotation should be included to evaluate for physeal injury.

Question 21

Quais são as duas estruturas que estão em maior risco na colocação dos portais artroscópicos no ombro?

Answer 21

The axillary and suprascapular nerves are the two structures at most risk during shoulder arthroscopic portal placement.

Question 22

Qual estrutura anatômica mais próxima em risco de lesão?

Answer 22

The nearest anatomical structure at risk is the suprascapular artery.

Question 23

Qual é a distância entre o nervo axilar e a AAC? E entre o nervo supraescapular e o labrum posterosuperior e o tuberculo supraglenoidal?

Answer 23

Nassar et al. found that the distance between the acromioclavicular joint and the axillary nerve is 7.9 cm for men and 6.37 cm for women. Bigliani et al. found the suprascapular nerve to be located 1.8 cm from the posterosuperior labrum and 2.5 cm from the superior glenoid tubercle.

Question 24

Qual estrutura está em menor risco no portal de Neviaser? E no portal lateral?

Answer 24

The suprascapular artery and nerve are at low risk with the Neviaser portal. The axillary nerve is at low risk in lateral portals.

Question 25

Qual estrutura anatômica é violada no portal de Wilmington?

Answer 25

Portal of Wilmington crosses the supraspinatus tendon at the myotendinous junction.

Question 26

Caso esteja programada a artroscopia da AAC, o que deve ser feito antes do início do procedimento?

Answer 26

If arthroscopy of the acromioclavicular joint is planned, an 18-gauge spinal needle should be inserted into this joint at the beginning of the procedure because extravasation of fluid during the shoulder and subacromial arthroscopy makes later identification of this joint dificult.

Question 27

Qual é o primeiro portal a ser feito na artroscopia do ombro?

Answer 27

The posterior portal is the primary entry portal for shoulder arthroscopy. When a posterior procedure is the main focus, some surgeons prefer to make an anterior portal first then the posterior portals under direct vision.

Question 28

Qual é a localização do portal posterior “soft spot”? Entre quais estruturas ele passa? Qual a sua finalidade?

Answer 28

This portal is located 1.5 to 3.0 cm inferior and 1.0 cm medial to the posterolateral tip of the acromion, between the infraspinatus and teres minor muscles. For visualization, this portal works well.

Question 29

O portal posterior “às 7 horas” permite a visualização de qual estrutura?

Answer 29

Allows direct access to the inferior glenohumeral capsule and avoids damage to the nearby structures.

Question 30

Quais são as duas técnicas para se estabelecer o portal posterior às “7 horas”?

Answer 30

The inside-to-outside portal is created by using a switching stick passed through the 3-o’clock portal and directed posteroinferiorly. The switching stick is brought through a small skin incision and then left in place. The outside-to-inside 7-o’clock portal is established by making a small skin incision 2 to 3 cm inferior to the posterior viewing portal.

Question 31

O portal artroscópico anterior do ombro permite avaliar quais estruturas?

Answer 31

For complete diagnostic examination of the shoulder, an anterior portal is essential to allow observation of the posterior capsule and the rotator cuff and for an anterior view of the glenohumeral ligaments and the subscapularis tendon.

Question 32

Quais são os parâmetros anatômicos descritos para se estabelecer o portal anterior no ombro?

Answer 32

The most commonly described anterior portal is made slightly lateral to a point halfway between the anterolateral tip of the acromion and the coracoid process.

Question 33

Quais são os parâmetros anatômicos para se estabelecer o portal antero-inferior do ombro?

Answer 33

The antero-inferior portal is made just lateral and slightly superior to the palpable coracoid process.

Question 34

Quais são os parâmetros para se estabelecer o portal anterolateral do ombro?

Answer 34

The anterolateral portal described by Altchek is made approximately 1 cm lateral to the anterolateral tip of the acromion and enters the glenohumeral joint through the rotator interval.

Question 35

Para reparos labrais superiores, qual portal artroscópico deve ser utilizado?

Answer 35

For repair of superior labral pathological conditions, an accessory anterosuperior portal just anterior to the acromioclavicular joint may be needed.

Question 36

Quais são os 2 métodos para estabelecimento do portal anterior? Quais são os limites do soft spot anterior?

Answer 36

Two basic methods are used to establish the anterior portal: antegrade (outside-in) and retrograde (inside-out). With both methods, the cannula passes through the anterior soft spot, which corresponds to an intraarticular triangle bounded by the intraarticular portion of the biceps tendon superiorly, the superior intraarticular portion of the subscapularis tendon inferiorly, and the anterior edge of the glenoid at the base.

Question 37

Quais estruturas estão no caminho do portal antero-inferior às 5 horas? Qual estrutura pode ser acessada com esse portal?

Answer 37

Both the cephalic vein and the anterior humeral circumlex artery are in the path of this portal, but a blunt passer rod or cannula can efectively push these aside. This allows appropriate access to the leading edge of the inferior glenohumeral ligament.

Question 38

Qual é a utilidade do portal superior de Neviaser?

Answer 38

This portal is most useful for passage of suture retrieval devices for rotator cuff repair.

Question 39

Quais estruturas cercam o portal superior de Neviaser?

Answer 39

It is bound anteriorly by the clavicle, laterally by the acromion, posteriorly by the base of the acromion and the scapular spine, and inferiorly by the posterosuperior rim of the glenoid.

Question 40

Qual a distância do nervo e arteria supraescapulares do portal superior?

Answer 40

The suprascapular nerve and artery lie approximately 3 cm medial to the superior portal at its closest point.

Question 41

Quais são os parâmetros para se estabelecer o portal superior de Neviaser?

Answer 41

Introduce an 18-gauge spinal needle 1 cm medial to the medial acromion at an angle of 30 to 45 degrees to the skin and 10 degrees posteriorly to enter the joint at the superior margin of the glenoid just posterior to the attachment of the long head of the biceps tendon.

Question 42

Qual é a localização do portal artroscópico lateral?

Answer 42

It is located 3 cm lateral to the lateral border of the acromion and passes through the deltoid muscle.

Question 43

Qual o local de passagem do nervo axilar em relação a borda lateral do acrômio?

Answer 43

The axillary nerve lies approximately 5 cm distal to the lateral border of the acromion.

Question 44

Qual a localização dos portais acessórios descritos por Burkhart para tratamento artroscópico de SLAP?

Answer 44

Burkhart described two lateral portals for repair of SLAP lesions. Depending on the site of disruption, he used an anterolateral portal, 1 cm lateral and posterior to the antero-lateral corner of the acromion, or a posterolateral portal, 1 cm anterior and lateral to the posterolateral corner of the acromion.

Question 45

Qual a utilidade do portal posterior de Wilmington?

Answer 45

This posterolateral accessory portal is used to approach posterior type II SLAP lesions, providing access to the glenoid and superior labrum.

Question 46

Quais são os parâmetros anatômicos para o estabelecimento do portal posterior de Wilmington?

Answer 46

The location is 1 cm anterior and 1 cm lateral to the posterior acromial angle. Care should be taken when placing this portal so as not to damage the rotator cuff near its attachment to the greater tuberosity.

Question 47

Qual é a ordem e sequencia das estruturas analisadas na artroscopia do ombro com o paciente em decúbito lateral?

Answer 47

Posterior Portal:
1- If the patient is in the lateral decubitus position, systematic examination begins with observation of the superior part of the shoulder joint or biceps tendon and the glenoid articular cartilage;
2- As the arthroscope is advanced into the joint, the articular cartilages of the glenoid and the humeral head are seen;
3- As the arthroscope is advanced anteriorly, the superior and inferior surfaces of the biceps tendon, the biceps anchor, and the superior labrum are evaluated carefully for evidence of a partial tear;
4- The bicipital arch formed by the superior glenohumeral ligament and the coracohumeral ligaments should be carefully evaluated to ensure that the biceps is stable and centered in the arch. A SLAP lesion may be seen and should be probed to determine stabilit;
5- The arthroscope is advanced over the anterior labrum, the soft spot that is bound by the biceps tendon proximally, the subscapularis tendon distally, and the articular surface of the glenoid inferiorly.

Anterior portal:
6- The biceps-labral complex is probed and evaluated, and the anterior labrum is examined for fraying or detachment indicating shoulder instability.
7- The arthroscope is now directed to view more inferiorly for examination of the anterior band of the inferior glenohumeral ligament and the middle glenohumeral ligament.
8- As the arthroscope is passed into the inferior pouch, the glenohumeral ligaments and the labrum can be examined by rotating the lens back toward the superior glenoid;
9- By using the trocar and obturator in the anterior portal, the humeral head can be gently lifted from the glenoid to evaluate the capsulo-labral attachments further.
10- The capsular attachment to the humeral head is examined;
11- The arthroscope is withdrawn slightly to examine the posterior humeral articular surface for chondromalacia and the posterior labrum for fraying or partial disruption, both of which indicate shoulder instability.
12- The scope is moved back toward the biceps tendon to complete the circle.

Question 48

O que é o complexo de Buford?

Answer 48

Snyder described another anatomical variant in this area, the so-called Buford complex. The cordlike middle glenohumeral ligament, which normally crosses the subscapular tendon and inserts into the glenoid neck in the 2-o’clock position, inserts directly into the biceps tendon, leaving a bare area on the glenoid with no labrum superiorly.

Question 49

Normalmente, qual o local de inserção da banda anterior do ligamento glenoumeral inferior no colo da glenóide?

Answer 49

Normally, the anterior band of the inferior glenohumeral ligament attaches to the glenoid neck between the 2-o’clock and 4-o’clock positions.

Question 50

O que é o “drive throuhg sign” de Warren?

Answer 50

The ease with which the arthroscope can be moved from superior to inferior in the joint should be determined. If moving the scope anteriorly is easy with the arm slightly externally rotated, the “drive-through sign” of Warren indicates generalized ligamentous laxity that must be corrected during any stabilization procedure.

Question 51

Quais são os 5 passos do guideline para avaliação do manguito artroscopicamente?

Answer 51

1. Supraspinatus tendon thickness is 9 to 12 mm.
2. Insertion site is 22 mm long, starting anteriorly at the biceps and extending posteriorly to overlap the infraspinatus at the apex of the bare area.
3. Medial to lateral insertion is approximately 17 mm, beginning adjacent to or within 1 mm of the humeral articular surface.
4. The infraspinatus spans the bare area.
5. A partial-thickness, 50% tear would have firmly attached, healthy fibers at about 8 mm from the articular surface.

Question 52

Como lesões parciais do manguito podem ser tratadas artroscopicamente?

Answer 52

Partial tears can be treated by lightly débriding the torn area to stimulate some localized bleeding for healing.

Question 53

Como distinguir uma lesão de Hill-Sachs e a área careca artroscopicamente?

Answer 53

A Hill-Sachs lesion has articular cartilage superior and inferior to the area of exposed bone, whereas the normal bare area of the humeral head has the cuff and small, normal-appearing vessels superiorly.

Question 54

Qual lesão indica impacto interno do manguito rotador?

Answer 54

Evidence of fraying of the rotator cuff with an associated “kissing lesion” on the posterosuperior glenoid labrum, as described by Jobe, indicates internal impingement of the rotator cuff.

Question 55

Qual o local de inserção no colo da glenóide da banda posterior do ligamento coracohumeral inferior?

Answer 55

Although not as prevalent as the anterior band of the inferior glenohumeral ligament, the posterior band may be visible with internal rotation as it approaches its insertion at the 7-o’clock to 9-o’clock positions posteriorly.

Question 56

Em qual região corpos livres e materiais de síntese perdidoas se encontram na articulação glenoumeral?

Answer 56

Loose bodies and loose hardware in previously operated shoulders may be found in the subscapular recess. Loose bodies tend to gravitate into the axillary pouch of the shoulder or occasionally into the subscapular recess.

Question 57

Por que é importante não violar a extensão lateral da bursa subdeltoidea quando se realiza a artroscopia?

Answer 57

Beals et al. have shown important landmarks when operating in the subdeltoid bursa. They noted that the internal extent of the bursa is approximately 4 cm from the acromial edge with the axillary nerve always lateral to the bursa, on average 0.8 cm. One should not violate the lateral extent of the bursa arthroscopically. If an open repair technique is used, the palpable internal extent of the bursa can be used as the limit of safely splitting the deltoid.

Question 58

Quais são as vantagens da drenagem e desbridamento artroscópico?

Answer 58

Arthroscopic débridement (1) improves inspection, irrigation, and débridement compared with multiple needle aspirations; (2) allows breaking up of intraarticular loculations; (3) decreases the potential for postoperative scarring and stiffness that occur after formal arthrotomies; and (4) can be done several times if necessary.

Question 59

Qual é a contra-indicação para a realização de desbridamento artroscópico?

Answer 59

A contraindication to arthroscopic débridement is an adjacent soft tissue abscess.