Arthroscopic "Panorama" View of the Subacromial Space via Deltoid Fascia Release

Abstract

Proper visualization is of paramount importance during arthroscopic rotator cuff repair. We propose a technique that significantly improves the visualization of the rotator cuff when viewing from the anterolateral or lateral portals. This "panorama" view is obtained by a release of the deep layer of the deltoid fascia, which in turn increases the space between the humerus and the deltoid muscle. This release increases the volume of the subdeltoid bursa, secondarily increasing the field of view of the subacromial space with the camera viewing from the anterolateral or lateral portals. This technical note describes a new technique useful in obtaining an excellent view of the subacromial space proving very useful in both the diagnosis and treatment of rotator cuff pathology.

Fig 1

View of the right subacromial space from the posterior viewing portal. The humeral head is marked with an asterisk, and the arrow indicates the direction of the deltoid fascia release with the radiofrequency ablation device in the line of the deltoid fibers.

Fig 2

View of the right subacromial space from the posterior portal. The humeral head is marked with the asterisk, and the arrow indicates the direction of the deltoid fascia release with the radiofrequency device.

Fig 3

View of the right subacromial space from the posterior portal shoulder. The acromion is marked by the asterisk. The dotted line outlines the acromial lateral and anterior edges. The deltoid fascia release is continued right up to the lateral edge of the acromion.

Fig 4

View of the right subacromial space from the posterior portal. The acromion is marked by the asterisk. The dotted line outlines the acromial lateral and anterior edges. The deltoid fascia has been released off the lateral acromial edge and is continued around the anterior edge of the acromion.

Fig 5

View of the right subacromial space from the posterior portal. The deltoid fascia is marked by the asterisk. The arthroscopic shaver is inserted through the anterolateral portal (arrow) and the deltoid fascia is gently removed posterior to the anterolateral portal.

Fig 6

View of the right subacromial space from the posterior portal. The inferior extent of the subdeltoid bursa is marked by the asterisk. The deltoid fascia is removed inferiorly from the subdeltoid bursa ensuring not to exceed 3-4 cm distal to the lateral acromial edge thereby not endangering the axillary nerve.

Fig 7

View of the right subacromial space from the posterior portal. The humeral head is marked by the asterisk. The deltoid fascia is removed from the anterior subacromial space ensuring expansion of the subdeltoid space.

Fig 8

View of the subacromial space with the camera in the right shoulder anterolateral portal after the deltoid fascia release. Here the “panorama” view of the proximal humerus and cuff is shown after the complete deltoid fascia release has been performed. An excellent wide-angle view is appreciated with the whole cuff visible in the single view.

Fig 9

View of the subacromial space with the camera in the posterior portal of the right shoulder. Here, we are measuring the deltoid to humerus distance with the tap used for the suture anchor placement. Before the deltoid fascia release, the distance is 7 mm. The humeral head is marked with the asterisk, and the arrow marks the anterolateral portal.

Fig 10

View of the subacromial space with the camera in the posterior portal of the right shoulder. Here, we are measuring the deltoid to humerus distance with the tap used for the suture anchor placement. Here, it measures 19 mm after the deltoid fascia release. This represents an increase of 12 mm or 170% of the deltoid to humerus distance.