In-Office Nano-Arthroscopy of the Shoulder with Acromioplasty

Abstract

Subacromial decompression with acromioplasty is among the most commonly performed shoulder procedures. The advantages of in-office nano-arthroscopy include the capability of diagnosing and treating subacromial impingement, swifter patient recovery, improved cost-effectiveness, and superior patient satisfaction. The purpose of this technical report is to describe our technique for performing in-office nano-arthroscopy for subacromial decompression (subacromial bursectomy and acromioplasty), with a particular focus on appropriate indications, providing sufficient local anesthesia, optimizing visualization, and discussing the advantages of the in-office setting compared to the operating room.

Fig 1

In-office nano arthroscopy standard shoulder setup. The patient is seated comfortably on an examination table, with the back of the bed set to approximately 70° to 80°, and the ipsilateral shoulder is prepped and draped in sterile fashion. A well-padded mayo stand is used to support the arm in slight forward flexion and abduction, which facilitates entry into the subacromial space.

Fig 2

The prepped and draped right shoulder with the patient in an upright, beach chair position, with the bed set at approximately 70° to 80°. Relevant surface anatomy markings include the acromion, clavicle, and coracoid. The posterior portal, which is the primary viewing portal, is made approximately 2 cm inferior and 2 cm medial to the posterolateral border of the acromion. The anterior portal, which is the primary viewing portal, is made 1 cm lateral to the coracoid. If needed, the lateral, working portal is made 1 cm distal to the lateral edge of the acromion.

Fig 3

Arthroscopic view of the left shoulder through the posterior portal. With a 2 mm shaver in the anterior portal, subacromial bursectomy is performed to expose the lower surface of the acromion, as well as the anterior and lateral edges. The bursectomy proceeds in an organized fashion from anterior to posterior and from lateral to medial.

Fig 4

Arthroscopic view of the left shoulder through the posterior portal. With a 3 mm NanoResection burr (Arthrex) in the anterior portal, acromioplasty is performed by gradual resection of anterior and lateral bone spurs, working from lateral to medial in the posterior portal and from anterior to posterior in the lateral portal. Laterally, care is taken to avoid the muscle fibers of the deltoid. Depending on surgeon preference, an additional lateral portal can be made and used for further bony resection. Through the lateral portal, the acromioplasty can be continued while viewing from the posterior portal, followed by the burr in the posterior portal while viewing from the lateral portal to ensure complete resection of any osteophytes.

Fig 5

Arthroscopic view of the left shoulder through the posterior portal. An electrocautery, 90° ablator (Apollo RF MP90 aspirating ablator; Arthrex) is inserted into the anterior portal and is used intermittently to maintain hemostasis during the acromioplasty.