Following administration of interscalene regional anesthesia, place the patient in a beach-chair position for shoulder joint arthroscopy.

Assess the range of motion of the shoulder joint.

Perform standard preparation and draping.

Establish a routine posterior glenohumeral arthroscopy portal (Fig. 1-A).

Introduce the arthroscope into the glenohumeral joint via the posterior portal.

Inspect the glenohumeral joint.

Establish the anterior portal under direct vision using a spinal needle lateral to the coracoid process (Fig. 1-B). The spinal needle is used to ensure that the instruments can access the inferior aspect of the joint capsule and, if possible, the posterior aspect of the capsule. Position the anterior portal just superior to the upper border of the subscapularis tendon.

Release the tissue in the rotator cuff interval to the anterior border of the long head of the biceps and medially to the base of the coracoid process under direct vision using a 3.0-mm CoVac 50 ArthroWand (ArthroCare, Sunnyvale, California) and/or an arthroscopic punch.

Divide no more than the upper half of the intra-articular subscapularis tendon (Fig. 2).

Through the anterior portal, cut the anterior-inferior aspect of the capsule completely, approximately 2 mm lateral to the glenoid labrum (Fig. 3 and Video 1).

As there are no helpful anatomical landmarks with which to judge the optimal location of the posterior-inferior portal, determine its location with a spinal needle. The tip of the spinal needle should be able to reach the posterior-inferior aspect of the capsule from at least the 5 to 11 o’clock position (Figs. 4-A and 4-B).

Release the posterior-inferior aspect of the capsule of the joint using the arthroscopic wand via the posterior-inferior portal. Aim for a complete 360° release of the joint capsule.

Alternatively, if access to the posterior or inferior aspect of the capsule is technically challenging, perforate as much of the posterior-inferior aspect of the capsule as possible using the arthroscopic wand.

Gently manipulate the arm and assess the range of motion of the glenohumeral joint. Start the arm manipulation in abduction, followed by forward flexion and backward flexion. Next, externally and internally rotate the arm. The surgical assistant should hold the shoulder girdle firmly using both hands to stabilize the scapula.

Inject 10 mL of Depo-Medrol (methylprednisolone) with lidocaine into the glenohumeral joint for pain relief.

Close the portals and apply a soft bulky dressing. No arm sling is needed.

Idiopathic adhesive capsulitis

Shoulder joint stiffness related to osteoarthritis

Active joint infection

The axillary nerve is the important anatomic structure at risk during this procedure. The axillary nerve is closest to the glenohumeral joint capsule between the 5 and 7 o’clock positions. Anatomic studies showed that, during abduction and external rotation of the arm, the axillary nerve stays in its position while the glenohumeral capsule tightens, which increases the distance between the two structures⁵. Thus, when the arthroscopic capsular release is performed, the incision of the inferior half of the glenohumeral joint capsule should preferably be made with the arm abducted and externally rotated.

Damage to the long head of the biceps tendon anchor should be avoided.

The shoulder should not be immobilized after the surgery; postoperative exercises should start immediately, on the day of the surgery.

To optimize the arthroscopic view during surgery, we prefer to use an automatic pump system for the inflow and outflow control of the saline solution into the glenohumeral joint.

When there is a partial or full-thickness tear of the rotator cuff, it can be repaired during the same operative session with use of the tendon undersurface repair technique⁶. Establish a lateral portal under direct vision using a spinal needle. Debride the edges of the torn tendon using a shaver system. The tendon can be repaired with an inverted mattress suture and a knotless suture anchor (OPUS AutoCuff System, ArthroCare).

A portion of the intra-articular subscapularis tendon is also divided during surgery as this improves the range of motion of the shoulder joint postoperatively⁷.