Arthroscopic Removal of Proximal Humerus Plates in Chronic Post-traumatic Shoulder Stiffness  Deepak N. Bhatia, M.S.(Orth), D.N.B.(Orth)  Arthroscopy Techniques  Volume 6, Issue 2, Pages e375-e381 (April 2017) DOI: 10.1016/j.eats.2016.10.014 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 Anteroposterior radiograph of the right shoulder shows a long plate and 5 regions of screw positions that need to be accessed for removal. The proximal 4 regions (superior [SUP], middle [MID], inferior [INF], and calcar [CAL]) can be accessed arthroscopically. The distal region (DIS) of a long plate is at the level of the deltoid insertion, and arthroscopic access to this distal region is difficult. (AC, acromion; CL, clavicle; GL, glenoid; PX, proximal humerus.) Arthroscopy Techniques 2017 6, e375-e381DOI: (10.1016/j.eats.2016.10.014) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 Portals used for arthroscopic plate removal are shown from the posterior (A) and anterior (B) aspects of a right shoulder in the beach chair position. The standard posterior (SP) and posterolateral (PL) portals are used for viewing throughout the procedure. The anterior (A) portal is used for glenohumeral adhesiolysis, and the anterosuperolateral (ASL) portal is used for deltoid retraction. The lateral (L) and inferolateral (IL) portals are placed above and below the axillary nerve (arrow, white dotted line) and are used for removal of screws. The plate (P) portal is used for removal of the distalmost screws and for exteriorization of the plate. The dotted black line marks the old surgical scar. (INF, inferior; LAT, lateral; MED, medial; SUP, superior.) Arthroscopy Techniques 2017 6, e375-e381DOI: (10.1016/j.eats.2016.10.014) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 Glenohumeral arthroscopy is performed via a standard posterior portal and intra-articular adhesions are shown in a right shoulder (beach chair position). (A) Adhesions (Ad) between the rotator cuff (SS) and humeral head (H) are seen. (B) The long biceps tendon (BT) is adherent (arrows) to the rotator interval tissue (RI). Arthroscopy Techniques 2017 6, e375-e381DOI: (10.1016/j.eats.2016.10.014) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 (A) A completed subacromial bursectomy is shown (right shoulder, beach chair position) and is performed prior to subdeltoid adhesiolysis. The subdeltoid adhesions (SD) completely cover the plate, and the deltoid (DL) is seen scarred to the proximal humerus. (B) The subdeltoid adhesions are excised using a radiofrequency probe (RF), and this exposes the superior border of the plate (HP) via the lateral portal (L). (Ac, acromion; DL, deltoid; H, humeral head; RC, rotator cuff.) Arthroscopy Techniques 2017 6, e375-e381DOI: (10.1016/j.eats.2016.10.014) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 Deltoid retraction maneuver is shown in a right shoulder in the beach chair position. (A) An anterosuperolateral (ASL) portal is established to access the subdeltoid adhesions (SD). The needle is directed inferiorly along the length of the plate. (B) A Wissinger rod (WR) is used to retract the subdeltoid scarred tissue (SD) and deltoid (DL) away from the plate (HP) for further dissection. (H, humeral head.) Arthroscopy Techniques 2017 6, e375-e381DOI: (10.1016/j.eats.2016.10.014) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 The posterolateral (PL) portal is established under vision while viewing from the posterior portal (right shoulder, beach chair position). A needle is used to determine the portal site via an outside-in technique. (ASL, anterosuperolateral portal; DL, deltoid; HP, humeral plate; SD, subdeltoid adhesions; WR, Wissinger rod.) Arthroscopy Techniques 2017 6, e375-e381DOI: (10.1016/j.eats.2016.10.014) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 7 (A) The superior row of screws (Scr1) is exposed in a right shoulder, and a screwdriver (Drv) placed via the lateral portal disengages the screw (Scr1) from the plate (HP). The middle-level screw (Scr2) is seen covered with adhesions (SD). (B) Outside view of the right shoulder (beach chair position) shows the transdeltoid screw removal technique. The screw (Scr) is exteriorized via the lateral (L) portal, and a forceps is used to depress the skin to visualize the screw head (left image). The driver (Drv) continues to withdraw the screw, and the head is grasped by a forceps for removal (right image). (Ac, acromion; ASL, anterosuperolateral portal; CL, clavicle; INF, inferior; LAT, lateral; MED, medial, viewing via the posterolateral [PL] portal; Sco, scope; SUP, superior.) Arthroscopy Techniques 2017 6, e375-e381DOI: (10.1016/j.eats.2016.10.014) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 8 (A) Left image: The calcar screw (CLC) is shown in a right shoulder (beach chair position) via the posterolateral viewing portal. The Wissinger rod (WR) is passed via the anterosuperolateral portal and is used to retract the deltoid (DL) and subdeltoid adhesions (SD) away from the plate (HP). Right image: The calcar screw is seen passing out via the transdeltoid inferolateral portal (IL). The inferior trajectory of the screw and the low lateral placement of the IL portal protect the axillary nerve. (B) Outside view of the right shoulder (beach chair position) shows the transdeltoid calcar screw removal technique. The calcar screw (CLC) is exteriorized via a screwdriver (Drv) placed through the inferolateral (IL) portal. The IL portal is 7-10 cm below the acromial and is at a safe distance from the axillary nerve (dotted line, arrow). (Ac, acromion; ASL, anterosuperolateral portal; CL, clavicle; INF, inferior; L, lateral portal; LAT, lateral; PL, posterolateral portal; Sco, scope; SSS, scapular spine; SUP, superior; WR, Wissinger rod.) Arthroscopy Techniques 2017 6, e375-e381DOI: (10.1016/j.eats.2016.10.014) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 9 Plate (PLT) removal is performed via the 1-inch plate portal (P) (right shoulder, beach chair position). The P portal incision is shown along the previous surgical scar (black dotted line). The P portal is in the region of deltoid insertion, and distal screws of long plates can be removed via this portal. (A, anterior portal; ASL, anterosuperolateral portal; IL, inferolateral portal; Inf, inferior; L, lateral portal; LAT, lateral; PL, posterolateral portal; Sco, scope; SP, standard posterior portal; SSS, scapular spine; SUP, superior.) Arthroscopy Techniques 2017 6, e375-e381DOI: (10.1016/j.eats.2016.10.014) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 10 Proximal humeral (H) lateral surface is shown after plate removal (right shoulder, beach chair position). The subdeltoid space is inspected for remnants of transosseous sutures (Su), and these are excised using an arthroscopic grasper (Gr) and scissors (Bt). Any remaining subdeltoid adhesions (SD) and screw holes are debrided to clear the debris. (DL, deltoid; Inf, inferior; Sup, superior.) Arthroscopy Techniques 2017 6, e375-e381DOI: (10.1016/j.eats.2016.10.014) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions