Shoulder arthroscopy

The shoulder complex is the most mobile of the joints of the human body. It consists of five joints: two physiological (or false) and three anatomical.

The physiological joints are the sub-shoulder and scapular-sternal, the anatomical - the sternoclavicular, acromioclavicular, and shoulder-shoulder. For the normal functioning of the shoulder complex requires precise, coordinated and synchronous interaction of these joints.

What causes shoulder joint instability?

The medical literature has accumulated a large amount of information relating to the causes and mechanisms of post-traumatic, recurrent shoulder dislocation, however, many authors differ in assessing their role and place in the complex chain from acute traumatic dislocation of the shoulder to its recurrent instability. Among the domestic authors, the point of view of Yu.M. Sverdlov (1978), A.F. Krasnova, R.B. Akhmetzyanova (1982), D.I. Circassian-Zade et al. (1992): they believe that the main factor in the pathogenesis of this disease is muscular imbalance as a result of primary traumatic dislocation, which is not amenable to conservative treatment methods. Along with this, certain significance is attached to changes in paraarticular tissues, the stretched capsule with the shoulder-scapular ligaments. This is the first formation on the way of the dislocated head of the shoulder, the appearance of the dislocation depends on its strength and ability to resist the pressure of the head. Cartilage lip (attached to the edge of the articular process of the scapula) has a certain value in the stabilization system of the shoulder joint, which, according to Bankart, plays the role of a sucker that creates a "vacuum effect" between the humeral head and the articular process of the scapula (this effect greatly facilitates the rotation of the humeral head throughout the range of motion in the joint). Damage to the articular lip leads to horizontal instability of the shoulder joint. Among domestic orthopedists there was an opinion about the secondary role of this damage in the pathogenesis of habitual shoulder dislocation. DI. Circassian-Zade et al. (1992) the first of the domestic authors noted a very important fact: the main cause of the development of habitual shoulder dislocation and postoperative relapses is instability of the shoulder joint, due to the insufficiency of the shoulder-ligament apparatus of the shoulder joint. The instability of the shoulder joint, as a rule, is the result of damage to several different elements of the summit-ligament apparatus of the shoulder joint, each of which has a certain stabilizing function. It is obvious that in such patients it is impossible to restore the lost stability of the shoulder joint by methods that do not take into account the role of each damaged element.

To date, the theory of shoulder joint instability, proposed by JPJon, Scott Lephart (1995), is the most modern and scientifically based theory. Let us dwell on it in more detail.

Thus, capsular-ligamentous structures can significantly affect stability by providing afferent feedback - the reflex muscle contraction of the rotator cuff and biceps of the shoulder in response to excessive rotation and translational movements of the head of the shoulder. Damage to these structures leads to a significant deficit in the mechanism of afferent feedback, both in acute traumatic injury and in the gradual development of recurrent shoulder instability due to cumulative damage to the capsular-ligamentous structures. Surgical restoration of the normal anatomy of unstable joints leads to the restoration of proprioceptive sensitivity.

The mechanism of damage, the frequency of instability of the shoulder joint

Possible dislocation of any healthy shoulder, if the injury is quite strong. However, in some patients, instability of the shoulder joint may occur spontaneously, without significant injury due to excessive capsule size or other congenital abnormalities.

Numerous data analyzing the circumstances in which there is a traumatic instability of the shoulder joint, show that the displacement of the head of the shoulder occurs at a certain position of the upper limb. Of course, the shoulder can be deployed under the influence of a direct injury directed to the proximal shoulder, but an indirect, indirect force is the most common cause of anterior traumatic subluxation or dislocation. Anterior instability occurs when the shoulder is removed above the horizontal level, at the time of the combination of the forces of abduction, extension and external rotation and supination. Instability can also occur as a result of very strong muscle contractions or convulsive seizures.

The most common cause of acute traumatic instability of the shoulder is a fall with an emphasis on the arm. At the moment of impact of the palm on the ground, contact of the upper outer part of the humeral head with the anterior margin of the articular process of the scapula occurs. A peculiar lever with a fulcrum appears at the point of contact between the above zones, the long arm of the lever is located distal to this point, and the proximal part of the humeral head becomes the short arm. The ratio of the length of these shoulders is 1:20, as a result of which, at the end of the short lever, pressure develops on the surrounding tissues, which is several hundred kilograms, and the bone tissue is destroyed with an effort of 300 kg / cm ². This is the most typical mechanism for the occurrence of shoulder dislocations, although various deviations are possible. A characteristic consequence of such a mechanism of injury is the great destruction of the surrounding tissues. With such a lever mechanism, as the head of the shoulder moves away from the center of the articular process of the scapula, the severity of damage increases, therefore lower dislocations are more often accompanied by bone fractures, damage to blood vessels and nerves.

The greatest frequency among all instability of the shoulder joint falls on the anterior instability: according to various authors, it is 75-98%.

Rear traumatic shoulder dislocation is the rarest type of shoulder joint instability: it is encountered in 2% of cases. As a rule, it is the result of a severe direct injury, a car accident, surgery, electroshock treatment. In this type of instability, the head of the shoulder is displaced subacromially behind the articular process of the scapula, and very often an impression fracture of its posterior part occurs. With such instability, diagnostic errors are most frequent. According to the materials of Cyto them. N.N. Priorov, all errors were due to the fact that they did not perform an x-ray examination in axial projection.

The vertical instability of the shoulder joint was first described in 1859 by M. Meddeldorph in the form of a lower dislocation. In its pure form, this is a very rare direction of instability. This causes severe damage to the soft tissues, fractures in the proximal shoulder and the lower edge of the articular process of the scapula.

The upper dislocation, according to M. Wirth, was registered in the literature in 1834, he also reports 12 cases described. In modern literature there is little mention of this type of traumatic dislocation: there are reports of isolated observations. The usual reason for the occurrence of such damage is extreme force, directed forward and upward and acting on the withdrawn arm. With this displacement, fractures of the acromion, acromioclavicular joint, large tuberosity occur. Extreme soft tissue injuries occur with the joint capsule, rotator cuff, surrounding muscles. Neurovascular complications are usually present.

Traumatic acute and recurrent instability of the shoulder joint between the ages of patients from 20 to 30 years in 55-78% of cases occurs during sports.

Traumatic instability of the shoulder joint

The very first and detailed description of traumatic shoulder-shoulder instability refers to 460 BC. E., it belongs to Hippocrates. He first described the anatomy of the shoulder joint, the types of its dislocation and the first surgical operation that he himself had developed to reduce "the wide space into which the head of the shoulder is dislocated." In the following centuries, more accurate descriptions of the traumatic pathology of dislocation of the shoulder joint were published, but the question regarding the “main lesion” still remains a subject of controversy.

A traumatic defect that occurs in the posterior external part of the humeral head as a result of contact with the front edge of the articular process of the scapula during dislocation has long been identified.

In 1940, Hill and Sachs published a very clear and specific review, giving information about the pathological anatomy of the humeral head with shoulder dislocations. The essence of their message is as follows.

• Impression fracture of the humeral head occurs with most dislocations of the shoulder.
• The longer the head of the humerus remains stationed, the greater this defect.
• These impression fractures are usually larger with anteriorly dislocation than with anterior dislocations.
• The defect of the humeral head is usually larger and larger with repeated anterior dislocations of the shoulder.

Over the past decade, many authors have identified this damage arthroscopically in 82-96% of cases on large clinical material.

Moreover, the possibilities of arthroscopic surgery made it possible to significantly deepen the morphological understanding of Bankart damage. Thanks to the work of R. Minolla, PL Gambrioli, Randelli (1995), a classification of various variants of this damage was created. Damage to the capsular-ligamentous complex of the shoulder joint with recurrent shoulder dislocation is divided into five types.

• Classical damage Bankart - the cartilaginous lip is separated from the front edge of the articular process of the scapula, together with the capsule and the shoulder-shoulder ligaments.
• Incomplete damage to Bankart - the cartilaginous lip and the capsule of the shoulder joint are not completely detached from the articular process of the scapula.
• The capsule is cut off from the neck of the scapula, the cartilaginous lip is cut off and isolated. In this case, the capsule becomes clearly redundant, the lower humeral-shoulder ligament is overly stretched and shifted down. At the anterior margin of the articular process of the scapula, at the 2–4 o'clock position, bone-cartilage damage is determined, caused by the traumatic impact of the posterior external part of the humeral head during the first dislocation. This is a typical, most frequent injury with a recurrent anterior shoulder dislocation.
• Fracture of the anterior low bone rim of the articular process of the scapula, the lower shoulder-shoulder ligament is shifted down, the capsule is stretched, the cartilaginous lip may be absent at the position of 2-6 hours.
• Labral degeneration with anterior capsular excess. In these cases, the lesion is difficult to recognize due to cicatricial degeneration of the cartilaginous lip and complex of the shoulder-shoulder ligaments.

Training

Preoperative preparation is typical for an orthopedic patient and is not distinguished by specificity. The operation is performed under general endotracheal anesthesia. After a comparative examination, under anesthesia, both shoulder joints of the patient are placed on the operating table on a healthy side, the operated limb is fixed in a suspended state with a lead of 30 ° and anterior deviation of 15 °, in internal rotation, with a 5 kg load on the limb axis Artrex.

Arthroscopic stabilization of the shoulder joint

From the works of Perthes and Bankart, it is known about the importance of the complex of the humeral-shoulder ligaments and the cartilaginous lip in the stable functioning of the shoulder joint. In a very large percentage of cases (more than 90%) in the surgical treatment of traumatic shoulder dislocation, many authors found that these ligaments and the cartilaginous lip were detached from the anterior low margin of the articular process of the scapula. The lower shoulder-shoulder ligament functions as a primary static stop, preventing the humeral head from moving anteriorly during shoulder abduction. In addition, cartilaginous lip as anatomical formation contributes to the formation of 25-50% of the entire concavity of a relatively flat scapular cavity. Intact cartilaginous lip functions like the edge of a cup with a sucker, creating a vacuum effect in the loaded shoulder, which helps the muscles of the rotational cuff center the shoulder head in the articular fossa of the scapula with active amplitude of movements. After a traumatic shoulder dislocation, the functions of the humeral-shoulder ligaments and the cartilaginous lip are lost, primarily due to the loss of their anatomical connection with the scapula.

The blood supply of the cartilaginous lip is carried out, on the one hand, at the expense of the periosteum, on the other hand, at the expense of the joint capsule. After a traumatic separation of the cartilaginous lip, the healing process can only begin at the expense of the surrounding soft tissues. Fibroblastic healing in these cases is at risk. For these reasons, reconstructive measures associated with damage to these anatomical structures should first be directed to their fixation to the articular process of the scapula as early as possible.

The basis of the surgical technique of arthroscopic treatment of instability of the shoulder joint, we put the method described by Morgan and Bodenstab in restoring damage to Bankart. For the operation, the arthroscopic sets of the Storz and Stryker firms with the surgical instruments of the Artrex company were used.

After processing the operative field and applying a marker on the skin of the landmarks of the shoulder joint, from the back access in the direction to the medial part of the top of the coracoid process of the scapula, the shoulder joint is punctured with a syringe with a puncture needle. At the same time, the needle hitting the shoulder joint is felt in the form of a light “dip”, after which the synovial fluid begins to flow out of the needle. Next, 50-60 ml of saline for its joint cavity is injected into the joint cavity. After that, a 0.5-cm-long skin incision is made in the projection of the rear access. Through it, using a blunt trocar, repeating the direction of the puncture needle, an arthroscope case is inserted into the joint, the trocar is replaced with an optical arthroscope with a video camera. Through the front access, located between the top of the coracoid process and the head of the humerus, a plastic cannula is inserted into the joint along the guide conduit to drain fluid from the joint. Through this cannula, the necessary arthroscopic instruments are inserted into the joint, after which diagnostic arthroscopy of the shoulder joint is performed using a standard 30-degree arthroscope with a diameter of 4 mm.

The flow of fluid into the joint is carried out through the arthroscope housing using a mechanical pump (to maintain a constant pressure of saline in the joint). Experience shows that the use of a mechanical pump is safe and helps the surgeon to constantly monitor possible bleeding from the tissues. After Bankard damage is visually diagnosed (tearing of the anterior-lower part of the cartilaginous lip from the middle and lower humeroscapular ligaments and the capsule of the shoulder joint from the articular process of the scapula, sometimes with a bone fragment) necks.

When the detachment of the cartilaginous lip is small, it must be increased with the help of a special hand raspator.

Next, through the plastic cannula, an electro-rotational boron is injected into the joint for treating the bone surface (arthroscheuver), with its help the entire leading edge of the articular process of the scapula is processed to a bleeding bone wound.

This stage is very important, since it creates the conditions for fibroblastic healing between the damage of Bankart and the articular process of the scapula. I especially want to pay attention to a neat uniform treatment of the bone surface, so as not to damage the articular cartilage and not to disturb the spherical surface of the articular process of the scapula. When a point bleed from a bone is obtained, the depth of treatment is considered sufficient.

The detached shoulder-shoulder complex (lower shoulder-shoulder ligament + cartilaginous lip) is gripped with a special clamp-guide, shifted to the anatomical site of attachment on the articular process of the scapula and held in this position.

The next very important stage is the imposition of transglenoid sutures. A needle with an ear (30 cm long, 2 mm in diameter) is injected through the clamping head, the cartilaginous lip is pierced, the whole complex is displaced to the maximum (cranially) by 5-10 mm. This is a very important point in the physiological tension of the lower shoulder-shoulder blade and its fixation in the anatomical site of attachment at the anterior edge of the articular process of the scapula. At the same time, the needle should go 2-3 mm below the edge of the articular process, through the neck of the scapula at an angle of 30 ° and 10-15 ° medial to the glenoid plane. The needles are carried out with the help of a drill, the sharp end of the needles comes out through the back surface of the scapula neck and under the musculature under the skin. A 1 cm long incision is made with a scalpel, the sharp end of the spokes is inserted into it. The place of exit of the spokes on the scapular surface is pre-determined using a stereoscopic arc, which is fixed on the base of the clamp-guide, thus avoiding accidental damage to the supra-scapular nerve (n. Suprascapularis). A monophilic suture thread “polydioxanone” No. 1 is inserted into the needle of the needle. Removing the needle at the sharp end, a suture thread is passed through the soft-tissue complex and the neck of the scapula. The second needle is carried out in a similar way 1 cm above (cranial) first, the free end of the first thread is tied into its ear, the second thread is tied to it. With the passage through the scapula, the threads are brought into the skin incision 1 cm above the first. The ends of the first thread are tied together under the fascia of the subscapularis when removing the traction from the limb and arm give the position of the ghost and internal rotation.

A total of 3-4 such seams are placed, arranged in series from bottom to top. The seams reliably fix the cartilaginous lip on the articular process of the scapula in the anatomical position. In this case, the reconstructed complex of the humeral-shoulder ligaments and the cartilaginous lip should look like a stretched structure, and the lip should be located above the front edge of the articular process of the scapula, evenly along the entire perimeter.

The skin wounds are stitched and aseptic dressing. The limb is fixed in the internal rotation in the immobilization tire.

Thus, the main operational principle of an arthroscopic Bankcard suture in case of primary or recurrent post-traumatic instability of the shoulder joint is an anatomically grounded re-fixation of the glenoid labrum with the lig complex. Glenohumerale to the anterior margin of the articular process of the scapula. After arthroscopic re-fixation, the cartilaginous lip can again function as the site of attachment of these ligaments and as a sealing ring between the articular process of the scapula and the head of the humerus, providing a suction effect due to negative pressure in this space over the entire range of movements in the shoulder joint.

[1], [2], [3]

What causes instability of the shoulder joint?

The medical literature has accumulated a large amount of information related to the causes and mechanisms of the emergence of post-traumatic, relapsing shoulder dislocation, however many authors disagree about their role and place in the complex chain from acute traumatic shoulder dislocation to its recurring instability. Among domestic authors the point of view of Yu.M. Sverdlov (1978), A.F. Krasnov, R.B. Akhmetzyanova (1982), D.I. Cherkes-Zade et al. (1992): they believe that the primary in the pathogenesis of this disease is the violation of muscle balance as a result of a primary traumatic dislocation that does not lend itself to conservative methods of treatment. Along with this, a certain value is attached to changes in pararticular tissue, a stretched capsule with brachial ligament. This first formation on the path of the dislocated head of the shoulder, on its strength and ability to withstand the pressure of the head, the appearance of a dislocation depends. A certain value in the system of stabilization of the shoulder joint has a cartilaginous lip (attached to the edge of the articular process of the scapula), playing, according to Bankart, the role of the sucker creating a "vacuum effect" between the head of the humerus and the articular process of the shoulder blade (this effect greatly facilitates the rotation of the head of the humerus in the entire range of movements in the joint). Damage to the joint lip leads to horizontal instability of the shoulder joint. Among domestic orthopedists there was an opinion on the secondary role of this damage in the pathogenesis of the habitual dislocation of the shoulder. DI. Cherkes-Zadeh et al. (1992), the first of the domestic authors noted a very important fact: the main cause of the development of the habitual dislocation of the shoulder and postoperative relapse is the instability of the shoulder joint, caused by the inadequacy of the bag-joint apparatus of the shoulder joint. Instability of the shoulder joint, as a rule, is the result of damage to several different elements of the bag-joint apparatus of the shoulder joint, each of which has a certain stabilizing function. It is obvious that in such patients it is impossible to restore the lost stability of the shoulder joint by methods that do not take into account the role of each damaged element. Becomes the result of damage to several different elements of the bag-joint apparatus of the shoulder joint, each of which has a certain stabilizing function. It is obvious that in such patients it is impossible to restore the lost stability of the shoulder joint by methods that do not take into account the role of each damaged element. Becomes the result of damage to several different elements of the bag-joint apparatus of the shoulder joint, each of which has a certain stabilizing function. It is obvious that in such patients it is impossible to restore the lost stability of the shoulder joint by methods that do not take into account the role of each damaged element.

To date, the theory of instability of the shoulder joint, proposed by JPJon, Scott Lephart (1995), is the most modern and scientifically based theory. Let us dwell on it in more detail.

Thus, capsular-ligament structures can significantly influence stability by providing afferent feedback - reflex muscle contraction of the rotator cuff and biceps arm muscle in response to excessive rotation and translational movements of the head of the shoulder. Damage to these structures leads to a significant deficit in the mechanism of afferent feedback, both in acute traumatic injury and in the gradual development of recurrent shoulder instability due to the accumulated damage to the capsular-ligament structures. Surgical restoration of normal anatomy of unstable joints leads to the restoration of proprioceptive sensitivity.

Mechanism of damage, frequency of instability of the shoulder joint

Possible dislocation of any healthy shoulder if the injury is quite strong. However, in some patients, the instability of the shoulder joint can occur spontaneously, without significant injury - due to the excessive size of the capsule or other congenital abnormalities.

Numerous data analyzing the circumstances in which traumatic instability of the shoulder joint arises show that the displacement of the head of the shoulder occurs at a certain position of the upper limb. Of course, the shoulder can be dislocated under the influence of a direct trauma directed to the proximal part of the shoulder, but an indirect, indirectly acting force is the most common cause of anterior traumatic subluxation or dislocation. Anterior instability occurs when the shoulder is moved above the horizontal level, at the time of a combination of withdrawal forces, extensions and external rotation and supination. Instability can also arise as a result of very strong muscle contraction or convulsive attacks.

The most common cause of acute traumatic instability of the shoulder is a fall with an emphasis on the arm. When the palm touches the ground, a contact occurs between the upper arm of the head of the humerus and the anterior margin of the articular process of the scapula. There is a kind of lever with a point of support at the point of contact of the above zones, distal to this point is the long arm of the lever, and the shortest shoulder becomes the most proximal part of the head of the humerus. The ratio of the length of these shoulders is 1:20, as a result of which the pressure on the surrounding tissues is several hundred kilograms at the end of the short arm, and the bone tissue is destroyed at an effort of 300 kg / cm ². This is the most typical mechanism of the appearance of shoulder dislocations, although various deviations are possible. A characteristic consequence of this mechanism of injury is the great destruction of surrounding tissues. With such a lever mechanism, as the head of the shoulder is removed from the center of the articular process of the scapula, the severity of the lesion increases, so the lower dislocations are often accompanied by fractures of bone tissue, damage to blood vessels and nerves.

The greatest frequency among all instability of the shoulder joint is due to anterior instability: according to various authors, it is 75-98%.

The posterior traumatic dislocation of the shoulder is the rarest kind of instability of the shoulder joint: it is met in 2% of cases. As a rule, it is the result of severe direct injury, car accident, surgical intervention, treatment with electric shock. At this type of instability, the head of the shoulder is displaced behind the articular process of the scapula subacromially, and an impression fracture of its posterior part often occurs. With such instability, diagnostic errors are most frequent. Based on the materials of CITO them. N.N. Priorov, all the errors were due to the fact that they did not perform X-ray examination in the axial projection.

Vertical instability of the shoulder joint was first described in 1859 by M. Meddeldorph in the form of a lower dislocation. In its pure form, this is a very rare direction of instability. This causes severe damage to soft tissue, fractures in the proximal part of the shoulder and the lower edge of the articular process of the scapula.

The upper dislocation, according to M. Wirth, was registered in the literature in 1834, he also reported 12 cases described. In modern literature there is little mention of this type of traumatic dislocation: there are reports of single observations. The usual cause of such damage is an extreme force, directed forward and upward and acting on the assigned hand. At this displacement there are fractures of the acromion, acromial-clavicular junction, and large tuberosity. Damage to soft tissues of extreme degree occurs with the capsule of the joint, the rotator cuff, the surrounding muscles. There are usually neurovascular complications.

Traumatic acute and recurrent instability of the shoulder joint in the age of patients from 20 to 30 years in 55-78% of cases occurs in sports.

Traumatic instability of the shoulder joint

The very first and detailed description of traumatic humeroscapular instability refers to 460 BC. It belongs to Hippocrates. He was the first to describe the anatomy of the shoulder joint, the types of its dislocation and the first surgical operation that he himself developed to reduce "that wide space in which the head of the shoulder dislocates." In subsequent centuries, more accurate descriptions of the traumatic pathology of shoulder joint dislocations were published, but the question of the "main lesion" is still a matter of controversy.

The traumatic defect that occurs in the posterior armature of the head of the humerus as a result of contact with the anterior edge of the articular process of the scapula during dislocation has been identified long ago.

In 1940, Hill and Sachs published a very clear and specific survey that provided information on the pathological anatomy of the head of the humerus with shoulder dislocations. The essence of their message is as follows.

• Impression fracture of the head of the humerus occurs with most shoulder dislocations.
• The longer the head of the humerus remains dislocated, the greater this defect.
• These impression fractures are usually larger with an anterior dislocation than with anterior dislocations.
• The defect of the head of the humerus is usually larger and larger with repeated anterior dislocations of the shoulder.

Over the past decade, many authors on a large clinical material revealed this damage arthroscopically in 82-96% of cases.

Moreover, the possibilities of arthroscopic surgery allowed to significantly deepen the morphological view of Bankart's damage. Thanks to the work of R. Minolla, PL Gambrioli, Randelli (1995), a classification of various variants of this damage was created. Damage to the capsular-ligament complex of the shoulder joint with a recurrent dislocation of the shoulder is divided into five types.

• Classical damage Bankarta - the cartilaginous lip is separated from the anterior edge of the articular process of the scapula together with the capsule and the humeroscapular ligaments.
• Incomplete damage Bankarta - cartilaginous lip and capsule of the shoulder joint are not completely detached from the articular process of the scapula.
• The capsule is detached from the neck of the scapula, the cartilaginous lip is torn off and isolated. In this case, the capsule becomes clearly redundant, the lower humeroscapular ligament is excessively stretched and shifted downward. At the anterior margin of the articular process of the scapula, at the position 2-4 hours, the osteochondral lesion is determined, caused by the traumatic impact of the posterior armature of the head of the humerus during the first dislocation. This is a typical, most frequent damage with a recurrent anterior dislocation of the shoulder.
• Fracture of the anterior bony rim of the articular process of the scapula, the lower humerus ligament is displaced downward, the capsule is stretched, the cartilaginous lip may be absent in the 2-6 hour position.
• Labral degeneration with anterior capsular excess. In these cases, the lesion is difficult to recognize because of cicatricial degeneration of the cartilaginous lip and the complex of humeroscapular ligaments.

Arthroscopic stabilization of the shoulder joint

From the work of Perthes and Bankart, it is known about the importance of the complex of the humeroscapular ligaments and the cartilaginous lip in the stable functioning of the shoulder joint. In a very large percentage of cases (more than 90%) in the surgical treatment of traumatic shoulder dislocation, many authors have found the detachment of these ligaments and the cartilaginous lip from the anterior margin of the articular process of the scapula. The lower humerus ligament functions as a primary static limiter, which prevents the head of the humerus from moving anteriorly during the withdrawal of the shoulder. In addition, the cartilaginous lip as an anatomical formation contributes to the formation of 25-50% of the entire concavity with respect to the flat scapular cavity. The intact cartilaginous lip functions like the edge of a cup with a sucker, creating a vacuum effect in the loaded shoulder, which helps the muscles of the rotary cuff to center the head of the shoulder in the articular fovea of the scapula with an active amplitude of movements. After a traumatic shoulder dislocation, the functions of the humeroscapular ligament and the cartilaginous lip are lost, primarily due to the loss of their anatomical connection with the scapula.

The blood supply of the cartilaginous lip is carried out, on the one hand, by the periosteum, on the other hand - due to the capsule of the joint. After a traumatic detachment of the cartilaginous lip, the healing process can begin only at the expense of the surrounding soft tissues. In these cases, fibroblastic healing is threatened. For these reasons, the reconstructive measures associated with the damage to these anatomical structures should first of all be directed at their re-fixation to the articular process of the scapula as early as possible.

In the basis of the surgical technique of arthroscopic treatment of shoulder joint instability, we put the method described by Morgan and Bodenstab in restoring damage to Bankart. For the operation, artro-scopic sets of firms "Storz" and "Stryker" with surgical instruments of the firm "Artrex" were used.

Preoperative preparation is typical for an orthopedic patient and does not differ in specificity. The operation is performed with a general endotracheal anesthesia. After a comparative examination under anesthesia of both shoulder joints, the patient is laid on the operating table on a healthy side, the operated limb is fixed in a suspended state with an outlet of 30 ° and anterior deviation of 15 °, in internal rotation, with a 5 kg load on the special tire of the firm " Artrex ».

Further, after processing the surgical field and marking the shoulder with the marker on the skin, a shoulder with a puncture needle is punctured from the posterior access in the direction to the medial part of the apex of the beak-like process of the scapula. In this case, the needle penetration into the shoulder joint is felt as an easy "dip", after which the outflow of synovial fluid begins from the needle. Further, 50-60 ml of physiological solution for its joint cavity is injected into the joint cavity. After that, a cutaneous incision of 0.5 cm is made in the projection of the posterior access. Through it, using the blunt trocar, repeating the direction of the puncture needle, insert the arthroscope pencil into the joint, the trocar is changed to an optical arthroscope with a video camera. Through the front access, located between the apex of the coracoid process and the head of the humerus, On the guide conductor, a plastic cannula is inserted into the joint for the outflow of fluid from the joint. Through this cannula, the arthroscopic instruments are inserted into the joint, followed by diagnostic arthroscopy of the shoulder joint using a standard 30-degree arthroscope with a diameter of 4 mm.

The inflow of fluid into the joint is carried out through the casing of the arthroscope by means of a mechanical pump (to maintain a constant pressure of the physiological solution in the joint). Experience shows that using a mechanical pump is safe and helps the surgeon continuously monitor possible bleeding from the tissues. After the diagnosis of Bankart injury (the detachment of the anterior cartilaginous lip with the middle and lower humeroscapular ligaments and the capsule of the shoulder joint from the articular process of the scapula, sometimes with the bone fragment), the degree of mobility and depth of separation of the soft tissues from the scapula and neck.

When the detachment of the cartilaginous lip is small, it must be increased with a special manual raspator.

Then, through the plastic cannula, an electro-rotating boron for the treatment of the bone surface (arthroschever) is introduced into the joint, with it, the entire anterior edge of the articular process of the scapula is treated to a bleeding bone wound.

This stage is very important, as it creates the conditions for fibroblastic healing between the injury of Bankart and the articular process of the scapula. Especially it would be desirable to pay attention to accurate even treatment of the bone surface, so as not to damage the articular cartilage and not to break the spherical surface of the articular process of the scapula. When point bleeding from the bone is obtained, the depth of treatment is considered sufficient.

The detached humerus complex (the lower humerus ligament + cartilaginous lip) is seized with a special guide-clip, displaced to the anatomical attachment site on the articular process of the scapula and held in this position.

The next very important stage is the application of transglenoid sutures. Through the guide clamp, insert a spoke with an eye (length 30 cm, diameter 2 mm), pierce the cartilaginous lip, the entire complex is displaced maximally upward (cranial) by 5-10 mm. This is a very important moment in the physiological tension of the lower humerus ligament and its fixation in the anatomical attachment site on the anterior margin of the articular process of the scapula. In this case, the needle should pass 2-3 mm below the edge of the articular process, through the neck of the scapula at an angle of 30 ° and 10-15 ° medially to the glenoid plane. Conduction of the needle is carried out with the help of a drill, the sharp end of the needle exits through the back surface of the neck of the scapula and the subacute muscle under the skin. The incision is made with a scalpel 1 cm long, the sharp end of the needle is removed into it.(n. Suprascapularis). In the eye of the needle, a monophilic suture filament "polydioxanone" No. 1 is inserted. Remove the needle from the sharp end, pass the suture thread through the soft tissue complex and the neck of the scapula. The second needle is similarly made 1 cm higher (cranial) than the first, a free end of the first thread is tied in its eyelet, a second thread is attached to it. When passing through the scapula, the threads are removed into the skin incision 1 cm above the first. The ends of the first filament are connected to each other under the fascia of the subscapular muscle, when the traction from the limb is removed and the position of the reduction and internal rotation is given to the arm.

In total, 3-4 similar seams are placed, arranged in series from the bottom up. The sutures securely fix the cartilaginous lip on the articular process of the scapula in the anatomical position. In this case, the restored complex of the humeroscapular ligaments and the cartilaginous lip should look like a stretched structure, and the lip should be located above the anterior edge of the articular process of the scapula, evenly along the entire perimeter.

On the skin wound sutures and aseptic bandage. The limb is fixed in the internal rotation in the immobilization bus.

Thus, the main operational principle of arthroscopic suture in the case of primary or recurrent posttraumatic instability of the shoulder joint is anatomically substantiated reflexion of the glenoid labrum with the lig complex . glenohumerale to the anterior margin of the articular process of the scapula. After arthroscopic reflux, the cartilaginous lip can again function as the attachment site of these ligaments and as a sealing ring between the articular process of the scapula and the head of the humerus, providing a suction effect due to negative pressure in this space over the entire range of movements in the shoulder joint.