1.  Lateral decubitus

- stabilise patient with beanbag or lateral rests

- apply skin traction to forearm

- place traction pole at foot of table opposite surgeon

- suspend arm with 10 lb weight

- abduction 60°

- forward flexion of 20°

- tilt top shoulder posteriorly 30° so that glenoid is parallel wwith bed

- mark bony landmark

- prep & free drape


Lateral Decubitus Shoulder ArthroscopyShoulder Arthroscopy Lateral DecubitusShoulder Lateral Decubitus Arthrex


2.  Beachchair


A.  Beachchair table

- pillow under thighs

- arm draped free

- access to posterior shoulder

- head secured to Mayfield head ring


B.  Spyder / Tmax

- holds head secure

- good access to posterior shoulder

- hydraulic arm holder elminates need for assistant to hold arm


Shoulder Arthroscopy TmaxShoulder Arthroscopy Spyder




Shoulder Arthroscopy Portals


Posterior Portal


Shoulder Arthroscopy Posterior Portals


Main portal for arthroscopy


A.  Soft spot

- identify posterolateral acromion

- 2 cm medial & 2 cm inferior

- through deltoid

- between infraspinatous and T minor


Make stab wound at post portal

- introduce cannula & trocar

- tip towards coracoid process

- distract shoulder joint whilst inserting

- introduce arthroscope


B.  Variation

- if mainly performing subacromial / rotator cuff

- move portal lateral and superior

- 1 cm inferior and 1 cm medial to posterolateral acromion

- aims scope over cuff tear which is usually lateral

- increases distance from cuff vertically

- can view larger area


Additional portals


Anterior Glenohumeral Portals


Arthroscopy Anterior PortalShoulder Arthroscopy Portals Anterior


Rotator Interval

- biceps, glenoid & humeral head form a triangle with subscapularis in the base

- place anterior portals in this triangle above subscapularis, lateral to coracoid


Shoulder Arthroscopy Rotator IntervalRotator Interval


A.  Retrograde method

- direct scope into rotator interval

- advance until rests against anterior capsule at superior edge subscapularis

- light transilluminates skin at site of portal

- ensure lateral to coracoid

- remove scope from sheath

- insert Wissinger rod / switching stick through sheath

- make stab incision

- advance rod

- insert cannula over stick

- use portal for probe & instruments


B.  Direct / anterograde

- insert 19 gauge spinal needle

- always lateral to coracoid

- pass into rotator interval

- stab incision / switching stick / cannula


Anteroinferior portal

- just above SSC

- angle to get to anterior labrum / bankart repair

- 3 - 6 o'clock


Shoulder Scope Low Anterior Portal


Anterosuperior portal

- high in rotator interval

- in angle between humeral head and biceps

- working portal for suture exchange in stabilisation surgery

- good angle for anchor insertion for SLAP repair


Anterosuperior Glenohumeral portal


Posterior Portal



- insert switching stitch through camera cannula

- insert camera through anterior cannula

- pass cannula over switching stick



- inspect / probe / repair posterior portal


Shoulder Arthroscopy Posterior Portal


Posterolateral portal


For posterior labral tears

- inferior and lateral to posterior portal

- allows placement of the inferior anchor


Shoulder Posterior Portals 1Shoulder Posterior Portals 2


Posterior Subacromial Portal


Redirect posterior cannular with blunt trochar

- remove camers

- direct it superiorly immediately below acromion once through deltoid

- sweep trochar laterally to break adhesions


Lateral Subacromial portal


Working portal

- for subacromial decompression / ACJ resection / RC surgery

- 2 - 3 cm lateral to lateral acromion

- 1 - 2 cm posterior to anterior acromion

- usually in line midportion / posterior border of clavicle

- insert needle

- should be above cuff, below acromion

- parallel to acromion


Anterosuperiorlateral Portal / Port of Wilminton


Shoulder Scope Port WilmingtonShoulder Scope Port Wilmington 2




- passes through supraspinatous

- anterolateral border acromion

- can place more posteriorly to access posterior aspect of SLAP

- in this case will pass through infraspinatous


Superior portal Neviaser / Superomedial portal



- access posterior SLAP / decompress suprascapular nerve

- pass through RC / supraspinatous

- 1 cm medial to acromion

- 1 cm posterior to clavicle




A.  Pressure pump

- usually 40 - 50 mmHg

- can temporarily increase if required


B.  Adrenaline in bags

- 1 mg in each 3L bag


Examination of GHJ


Systematic Approach


A.  Glenoid medial / Humeral head lateral

- arthritis / chondral damage


Arthroscopy Humeral Head OAGlenoid OA Arthroscopy


B.  Biceps

- careful examination / probing of insertion

- examination of intra-articular portion for degeneration

- pull extra-articular portion into joint to confirm gliding well


Arthroscopy Normal Biceps InsertionArthroscopy Normal Biceps TendonArthroscopy Normal Biceps Tendon 2


C.  Labrum

- 360o examination

- anterior / inferior / posterior


Arthroscopy Normal Anterior LabrumShoulder Arthroscopy Inferior LabrumShoulder Arthroscopy Posterior Labrum


D.  Glenohumeral ligaments




Superior Glenohumeral Ligament



- crosses subscapularis vertically


MGHL Arthroscopy


Inferior / anterior aspect of IGHL

- attachment to labrum between 3 and 6 o'clock

- look down into inferior recess

- see attachment to inferior humerus

- exclude HAGL / exclude loose body


Arthroscopy Normal IGHL Humeral InsertionNormal IGHL Glenoid AttachmentShoulder Loose Body


E.  Rotator Cuff



- examine insertion

- ER the humerus


Arthroscopy Normal SubscapularisSubscapularis Normal Arthroscopy



- examine underside and insertion

- abduct and ER

- should be no gap between cartilage and insertion


Supraspinatous Normal ArthroscopySS normal arthroscopySupraspinatous Tendon Normal Crescent Variant



- insertion at posterior humerus next to bare area

- Hill Sach's lesion (has cartilage each side c.f. bare area)


Shoulder Arthroscopy Infraspinatous Insertion


Neurological Complications


Uncommon (0.1%)


1. Posterior Portal

- if placed inferiorly can damage AXN below Teres minor 


2. Anterior Portal

- damages MCN if medial to coracoid

- brachial plexus & axillary artery