For overhead athletes and, in particular, baseball pitchers, the rates of success and return to play for those who have undergone arthroscopic repair of type II SLAP lesions are poor, ranging from 7% to 62%. The reasons for the poor results and high failure rates in overhead athletes with type II SLAP repairs are multifactorial and are a combination of many factors. These factors include the failure to establish the diagnosis and treat these athletes preoperatively; the inability of the operating surgeon to differentiate normal anatomic variants from pathologic SLAP lesions at the time of surgery; the surgical technique, which may violate the rotator cuff; or the placement of suture anchors, which restricts external rotation and alters overhead throwing mechanics. The proper diagnosis of SLAP lesions can be difficult because SLAP tears rarely occur in isolation and are often associated with other shoulder pathology. A proper history detailing the onset of symptoms and whether there was an acute episode of trauma or a history of repetitive use is critical. It is important to remember that no single physical examination finding is pathognomonic for SLAP tears. When seen in isolation, SLAP tears may mimic impingement syndrome (52%) or even anterior instability (39%). Surgical treatment of type II SLAP lesions should not be undertaken lightly in overhead athletes. If a 3-month rehabilitation period followed by a return to sports over the following 3 months does not allow the athlete to return to his or her preinjury level, diagnostic arthroscopy with SLAP repair is a reasonable option and can yield excellent results using the proper techniques. The technique described in detail in this article and our video can be technically demanding, but with the key points outlined, it can be reproduced and provide excellent results for overhead athletes undergoing SLAP repair. By not violating the rotator cuff, using a mattress configuration and keeping the suture knot away from the articular surface, and by not going anterior to the biceps tendon for repair, external rotation and strength can be preserved, leading to an excellent result with a predictable return to play for overhead athletes.
Arthroscopic surgery of the shoulder joint and the subacromial space requires adequate visualization to be effectively performed. Visual clarity is essential to perform a safe and successful arthroscopic procedure. The major determinants to provide visualization in the subacromial space and the glenohumeral joint include adequate inflow (dependent on the dimension of the inflow cannula), flow rate versus pressure, pump system versus gravity, the use of electrocautery and radiofrequency devices, blood pressure control and hypotensive anesthesia, and the type of irrigation solution used with or without the use of epinephrine. In 2012, the cost of a 30-mL (30-mg) vial of epinephrine was $6 (adrenalin/epinephrine injection, USP, Par Pharmaceuticals), and approximately 3 to 4 bottles would be used on average for a single shoulder arthroscopy. In 2019, the same 30-mL bottle of epinephrine cost $237, a nearly 40-fold increase. The purpose of our study is to describe the various factors and techniques that can be used to maintain visual clarity in shoulder arthroscopy without the use of epinephrine in the irrigation solution and the cost savings associated without the use of epinephrine.A rthroscopic surgery of the shoulder joint and the subacromial space requires adequate visualization to be effectively performed. 1 Visual clarity is essential to perform a safe and successful arthroscopic procedure. 2 In particular, bleeding in the subacromial space is an annoying but ever-present impediment to visualization during arthroscopic subacromial procedures.
Purpose Arthroscopy is an efficacious and popular treatment modality in developed nations for a variety of musculoskeletal conditions. However, arthroscopy requires specialized training, complex infrastructure, and expensive equipment, occasionally causing barriers to use in developing countries. Consequently, the utilization of resources to perform and teach arthroscopy in low- and middle-income countries (LMICs) is controversial. Through this investigation, we assessed the current capacity and barriers to arthroscopy use and training in these settings. Methods Focused interviews were conducted with surgeons from Haiti (low-income) and Romania (middle-income) regarding their experience with arthroscopy. Based on responses, a multiple-choice survey was developed and administered to orthopaedic trainees and practicing orthopaedic surgeons during national orthopaedics conferences in each country. Results Fifty-eight orthopaedists in Haiti, and 29 in Romania completed the survey. Most (91% from Haiti; 79% from Romania) reported that learning arthroscopy is essential or important for orthopaedic training in their country. Yet only 17% from Haiti compared to 69% from Romania indicated their primary hospital has the equipment necessary for arthroscopy. In Haiti, equipment was the main barrier to use of arthroscopy, followed by training, while in Romania, the main barrier was training, followed by equipment. Simulations and telemedicine were ranked as top choices of effective methods for learning arthroscopy. Conclusions Regardless of their country’s resource limitations, most participants place high value on the practice of arthroscopy and arthroscopic training. The results from this study highlight a hierarchy of needs in developing nations. Furthermore, local providers report a strong belief in the need for arthroscopic treatment to benefit their patients, and a clear desire for further training and development of these techniques. By identifying similarities and differences by location, we may better tailor global orthopaedic training initiatives and partnerships in LMICs.
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