Shoulder Arthroscopy.

The purpose of this work is to present the current arthroscopic techniques used by the shoulder team at the Southern California Orthopedic Institute in Van Nuys, Calif.

In the initial chapter, the author presents various options available for learning shoulder arthroscopic technique. He reviews sources of arthroscopy literature and suggests specific materials for back@ ground reading. Related journals and videotapes are listed in tables. Relevant courses are listed and critiqued. This information, meant primarily for surgeons, can be useful to any health care professional who wishes ready access to timely training materials on shoulder arthroscopy.

The next two chapters review operating department preparation, and patient care and positioning prior to surgery. This is a valuable section for operating department personnel in orienting them to proper operative setup and may supplement materials used for in-service training. Later chapters address arthroscopic methods for entering the shoulder for diagnostic arthroscopy and bursoscopy, and focus on anatomical features of the shoulder including normal anatomy and its variations. Detailed information follows about specific arthroscopic procedures for treatment of rotator cuff problems, acromioclavicular joint injuries, instabilities, calcific tendinitis, and lesions involving the biceps tendon. Before reviewing operative procedures, the author adequately defines the nature of the specific lesion, reviewing clinical presentation, history, and etiology. Much of the text, however, details surgical technique. A brief, very interesting, and easy-to-read chapter follows on specific case studies that address other diagnoses treated via arthroscopic means, thereby advocating a wider application of shoulder arthroscopy. copy. The monograph ends with coverage of possible complicating factors in arthroscopic surgery and suggests strategies to avoid them.

Several areas warrant special mention. The chapters on diagnostic arthroscopy are most enlightening. The author presents diagnostic procedures and visualization techniques for the identification of anatomical features of the glenohumeral joint and the subacromial space. This information provides a foundation for later chapters on arthroscopic repairs. Here, the author stresses the importance of a 15-point anatomical inspection of glenohumeral anatomy and an 8-point identification of bursal anatomy, and he reviews the normal versus abnormal appearance of structures. A summary table clearly lists all structures to be identified in diagnostic arthroscopy. More importantly, the author also describes variations of normal anatomy that may be mistaken for abnormalities.

The chapters on labral lesions, rotator cuff repairs, and acromioclavicular joint lesions offer logical classification schemes for these diagnoses and serve to categorize information more clearly for the reader. After an informative presentation on the biomechanical role of the glenoid labrum, the author classifies labral lesions then further defines a subgroup of lesions within the superior portion of the labrum. He addresses surgical repair of each subgroup of superior labral tears. Also noteworthy is the classification scheme for acromial process morphology and the coverage of its ramifications for surgery. In a presentation of shoulder instability, the author reviews the history of the use of the arthroscope in instability surgery and presents techniques of choice. The surgical correction of anterior instability is presented in depth, whereas posterior instability is only briefly touched upon. Multidirectional instability is mentioned within the context of generalized ligamentous laxity without antecedent trauma. More relevant for physical therapists, however, is the coverage of the clinical findings of instability, a review of anatomy with emphasis on the specific supporting role of the glenohumeral ligament complex, and the classification of variations in glenohumeral ligament anatomy.

Although provocative diagnostic maneuvers for assessing instability, impingement, and acromioclavicular joint integrity are also presented, these procedures should already be familiar to orthopedic physical therapists. A presentation of findings manifest through radiographs, arthrograms, and magnetic resonance imaging studies better defines each lesion. Postoperative guidelines are briefly mentioned for biceps tendon repair, rotator cuff repair, and acromioplasty and for the repair of instability. These brief presentations provide only an overview of the rehabilitation process, with little mention of the special considerations of each diagnosis.

The text follows a logical progression in guiding the reader from operative setup, to arthroscopic examination, to arthroscopic repairs. Depth of coverage varies from the extensive presentation of surgical techniques for a wide variety of shoulder pathologies to the superficial mention of rehabilitation programs. Because heavy emphasis is placed on surgical techniques, much of the content is outside the realm of physical therapy and makes for very tedious reading.

This work is supplemented by a good number of drawings of excellent clarity and by radiographs and magnetic resonance imaging scans that help the reader to understand the text. There is an abundance of color photographs that were taken arthroscopically. Although captioned to describe their contents, the photographs are not labeled. Consequently, the structures depicted within them are very difficult to recognize. Given the microanatomy contained in the photographs, the use of arrows or other labels to pinpoint salient features would have yielded much greater clarity. A short introductory paragraph introduces the material to follow. The brief remarks of postoperative care are used as concluding remarks for several chapters in lieu of summarizing comments.

Seven of the 15 chapters contain a list of references. These references are both adequate and timely and contain citations from acknowledged leaders in the field of shoulder arthroscopy. Presumably due to the recentness of many arthroscopic procedures, long-term follow-up studies are not cited.

This work succeeds in summarizing the state-of-the-art experience of a shoulder team and enlightens the reader on the broad span of arthroscopic applications ranging from rotator cuff repairs to cyst removal. Physical therapists treating a generalized orthopedic caseload will find this work too specialized for their purposes poses. For the orthopedic physical therapist who treats many postsurgical shoulders, this work would have been greatly enhanced by better labeling and by more in-depth coverage of rehabilitation guidelines. Although clearly meant for those physicians who wish to acquire or perfect their arthroscopic surgical skills, orthopedic physical therapists will find this monograph useful in increasing their understanding of arthroscopic examination and reparative techniques.