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Initial Steps in Arthroscopic Acromioplasty

    - beach chair position is comfortable for both the patient and the surgeon and allows the option of converting to an open procedure (if necessary);
    - patients need to be seated with the torso raised to 70 deg with a foled sheet placed on the medial border of the affected scapula (to maximize posterior exposure)
    - simultaneously palpate posterolateral corner and anterior of the acromion and note the "arthoscopic plane";
           - if this plane is sloped too steeply, then the surgeon will have to hold the arthroscope in an awkward position (w/ the scope pointing upwards);
           - to remedy this problem, increase the patient's sitting angle which will bring the arthroscopic plane down to a more horizontal level;
    - complications: hypoglossal nerve injury;
    - reference:
           Hypoglossal nerve palsy after arthroscopy of the shoulder and open operation with the patient in the beach-chair position. A case report.

- Portal Placement:
    - generally arthroscopy of the shoulder joint is carried out prior to arthroscopic acromioplasty, and therefore, standard anterior  and posterior arthroscopic portals are established;
           - a self sealing cannula is usually placed thru the anterior portal;
    - anterior portal:
           - the arthroscope is driven anteriorly until the tip can be palpated near the anterior portal;
           - drive the arthroscope thru the anterior portal and then pull the scope back out of its cannula;
           - the arthroscopic cannula serves as a positioning guide for the anterior cannula which is then driven into the subacromial space;
           - a 5.5 mm shaver is placed into the anterior portal cannula and an inital arthroscopic bursectomy is carried out;
           - one adequate visualization of the subacromial space has been established, the lateral portal is established;

   - lateral portal: (see portal placement);
           - used as the main instrument portal (acromioplasty and bursal debridement);
           - lateral portal is inserted in the usual manner with care that its placement will allow full triangulation of the undersurface of the anterior acromion;
           - make sure that an 18gauge needle can get to the anteroinferior edge of the acromion and that it can be directed upwards for easier shaving;
           - if the portal is positioned too close to the acromion, resection of the anteromedial aspect of the acromion will be difficult;

- Plan to Control Bleeding:
    - pre-inject the subacromial space with 30 cc of 1:300,000 epinephrine solution;
    - if possible, have anesthesia lower the patient's blood pressure;
    - ensure that reserve fluid bags are present;
    - arthroscopic techniques:    
         - when the posterior subacromial portal is established, bluntly sweep the trocar across the undersurface of the acromion which helps to remove the bursal attachments;
         - minimize the use of the shaver to clear off the bursa, since this may stir up early bleeding;
         - use cautery or the arthrocare wand to carefully define the undersurface landmarks of the acromion;
         - be careful not to disturb the deltoid fascia which lies below the acromion since this is guaranteed to stir up bleeding;
    - air injection:
         - if bleeding obstructs the visualization, then shut off inflow and suction out the fluid;
         - inject 100 cc of air thru a syringe;
         - bleeding will then usually stop spontaneously

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