In-office needle arthroscopy may be effective for superior labral tear debridement
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Superior labrum anterior to posterior tears are commonly observed in overhead athletes and can significantly impact shoulder performance.
When nonoperative treatments, such as rest, anti-inflammatory drugs, physical therapy and corticosteroid injections, fail to provide symptomatic relief, surgical intervention, including superior labrum anterior to posterior (SLAP) repair, debridement and biceps tenotomy, are considered. SLAP repair is often effective in young patients; however, outcomes in middle-aged and older patients are generally less favorable, with increased revision rates. In these cases, SLAP debridement combined with biceps tenotomy or tenodesis may be more suitable. Stephen J. Snyder, MD, and colleagues originally categorized SLAP lesions into four types based on the severity of the labral tear and the stability of the biceps anchor, a classification later expanded by Mark W. Maffet, MD, and colleagues, as well as Shahla Modarresi, MD, and colleagues, to include 10 types. Types 1 and 3 are typically managed with debridement and potential labral repair, while types 2 and 4 often require SLAP repair or biceps tenotomy/tenodesis depending on biceps anchor degeneration.
Source: James J. Butler, MB, BCh, and John G. Kennedy, MD, MCh, MMSc, FRCS(Orth)
Recent innovations in in-office nano-arthroscopy (IONA) allow for awake, office-based arthroscopic procedures without an OR, nerve block or general anesthesia. This approach not only achieves high patient satisfaction but also supports a swift return to work and sports. With improvements during earlier designs, the 1.9-mm needle arthroscope incorporates an optic chip at the camera tip, eliminating rod lenses and delivering image quality comparable to traditional arthroscopy. This semi-rigid, durable system enables direct visualization and treatment of glenohumeral pathology using local anesthesia in an office or bedside environment. The IONA system includes an array of tools — burrs, punches, graspers, scissors, probes, shavers and resectors — suitable for treating various musculoskeletal conditions.
This report details an effective technique for the treatment of SLAP tears with IONA, highlighting local anesthesia administration, indication criteria, visualization technique and the advantages of office-based procedures instead of OR settings. This technique has previously been published in Arthroscopy Techniques.
Preparation
The patient is seated on the examination table, with the posterior, lateral and anterior shoulder regions exposed to allow unobstructed access. The arm is supported at roughly 30° of forward flexion. It is essential for the patient to stay relaxed so that the rotator cuff muscles do not restrict entry to the glenohumeral joint. Standard arthroscopic landmarks, including the anterior, lateral and posterolateral borders of the acromion; the anterior and posterior borders of the clavicle; the acromioclavicular joint; the coracoid process; and common posterior and anterior portal sites, are marked on the skin.
Given the 0° view of a needle arthroscope, the posterior portal may be positioned more laterally and proximally to enhance visualization of the posterior labrum. Additional lateral portals may be created to examine the labrum and any rotator cuff issues further, and a cannula may be inserted through the supraspinatus for improved visualization of the superior labrum. All portal sites are infiltrated with 20 mL of 1% lidocaine (10 mL at each site), and an additional 20 mL solution of 1% lidocaine mixed with 0.5% bupivacaine in a 1:1 ratio is injected through the posterior portal after 10 minutes to verify portal positioning and provide further anesthesia. In cases of subacromial impingement requiring arthroscopic debridement, 10 mL of lidocaine with epinephrine and ropivacaine in a 1:1 ratio is injected into the subacromial space. The extremity is then prepared and draped in a sterile manner, and a pre-procedure timeout is completed to confirm the correct surgical site.
Technique
A posterior arthroscopic portal is created with a No. 11 blade, making a 2-mm stab incision angled toward the coracoid and glenohumeral joint. Care needs to be taken to avoid cutting through the deltoid fibers to prevent bleeding that could impair visualization.
When a rotator cuff tear is suspected, the posterior portal may be placed slightly more lateral and proximal to the soft spot for optimal visibility of the rotator cuff and subacromial bursa.
A 2.2-mm cannula is introduced into the glenohumeral joint via the posterior portal, and the blunt trocar is exchanged for a 1.9-mm 0° needle arthroscope (NanoScope; Arthrex). The cannula is then attached to a fluid management system (DualWave; Arthrex), with optimal visualization achieved at 35 mm Hg pressure using a saline solution with added epinephrine to minimize bleeding. Diagnostic arthroscopy is conducted to examine the rotator interval, biceps tendon, superior labrum, glenohumeral ligaments, labrum, rotator cuff insertion and articular surfaces.
After diagnostic arthroscopy, the anterior portal is created under direct visualization with a spinal needle to ensure proper placement near the biceps tendon. A 2-mm incision is made without extensive cutting or spreading. Through this portal, a probe is used to assess inflammation or degeneration of the biceps tendon and the stability of the labrum. The probe is replaced by a 2-mm shaver to debride the superior labrum to a stable margin (Figures 1 and 2). A grasper can be used to extract loose bodies, and in cases where a biceps tendon tear or anchor damage is evident, a biceps tenotomy can be performed with a 2-mm biter if the patient is unsuitable for isolated SLAP repair. After surgery, portals are closed using adhesive wound strips or nylon sutures as needed, followed by a sterile dressing to support early shoulder motion.
Follow-up care
Postoperatively, patients are encouraged to mobilize the shoulder as comfortable, perform active wrist and finger movements, and supinate and pronate the forearm. Ice application and sling use are recommended for comfort within the first 24 to 72 hours.
A follow-up wound check is performed on postoperative day 5, after which formal physical therapy begins. Acetaminophen and anti-inflammatories are generally sufficient for pain control post-surgery.
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- For more information:
- James J. Butler, MB, BCh, and John G. Kennedy, MD, MCh, MMSc, FRCS(Orth), can be reached at the division of foot and ankle surgery at NYU Langone Health in New York.
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