Arthroscopic techniques have revolutionized the treatment of shoulder pathologies. Traditionally, these procedures rely on a distended joint filled with fluid for visualization and instrumentation. However, this article explores a novel approach: dry arthroscopy. We’ll delve into the technique, its advantages, and potential limitations, offering a “cowboy’s guide” to understanding and potentially implementing this advanced method. This article is inspired by the principles of del Piñal et al for dry arthroscopy of the wrist and further expands the possibilities of shoulder arthroscopic techniques.
The Dry Arthroscopy Technique: A Step-by-Step Guide
The dry arthroscopy technique, as described here, offers a unique approach to shoulder arthroscopy, minimizing the use of fluid and potentially offering several advantages.
Patients are positioned in the beach-chair position, foregoing traction. A standard posterior glenohumeral viewing portal is established, followed by the anterior portal under dry arthroscopic vision. Additional portals are created as needed.
Any existing synovial fluid or hemarthrosis is washed out and immediately aspirated using a synoviotome suction pump. Crucially, a free arthroscope sheath side valve remains open (except during washing) to prevent joint collapse and minimize bleeding caused by negative pressure or localized heat buildup during shaving or burring.
Joint exploration proceeds as in traditional wet arthroscopy, including dynamic assessment of the shoulder. Once pathology is identified (synovitis, labral tears, glenoid defects, etc.), appropriate instrumentation techniques are applied, mirroring the traditional method. No specialized equipment is required.
Dry arthroscopic Bankart repair illustrating glenoid preparation.
In many cases, hemostatic thermal probing is unnecessary. Active bleeding, if present, typically results in slow leakage into the axillary recess without compromising visualization, with hemostasis occurring spontaneously. When thermal probing is required, only a few intermittent applications suffice. Thermal tissue ablation or dissection is avoided.
Occasionally, the arthroscope lens may cloud over or become stained. Injecting a few milliliters of air or saline through the sheath’s side valve, or even gently rubbing the lens against intra-articular soft tissue, usually restores adequate visualization.
During bone socket creation, blood splashing can obscure the view. The lens is transiently retracted to maintain visualization. This maneuver is also useful during anchor insertion with a mallet.
The glenohumeral joint is sporadically washed with saline and immediately aspirated to restore a dry environment. This is sometimes needed after using instruments like ring curettes and rasps or when blood clots accumulate in the axillary recess.
Advantages of the Dry Approach: A Cowboy’s Perspective
Classic “wet” arthroscopy is the universally accepted gold standard. However, dry arthroscopy offers potential advantages:
- Physiological Environment: It allows assessment and treatment of lesions in a more natural biomechanical setting, free from the artificial distension caused by fluid. Multidirectional instability and other conditions can be evaluated more realistically.
- Preservation of Shoulder Anatomy: The absence of tissue infiltration preserves the shoulder’s shape, volume, and external anatomic landmarks during surgery. This can be especially beneficial when performing mini-open procedures in conjunction with arthroscopy.
Illustration of the dry technique and the visual quality maintained even with transient bleeding
- Reduced Need for Hemostasis: Active bleeding tends to be self-limiting, reducing the need for thermal probes and their associated risks to local vascularity and soft tissue.
- Larger Portals and Complex Procedures: The lack of fluid management concerns allows for the use of larger portals (even regular incisions), potentially expanding the scope of arthroscopic treatments, such as intra-articular osteosynthesis and bone grafting.
Dry arthroscopic Eden-Hybinette procedure highlighting bone graft placement and fixation.
Potential Pitfalls: Challenges in the Dry Landscape
Despite its advantages, dry arthroscopy has potential limitations:
- Visualization: The field of vision may occasionally be less clear or spacious compared to wet arthroscopy. However, simple techniques like air or saline injection can often resolve this.
- Thermal Probe Use: Dry arthroscopy may not be ideal for procedures requiring sustained use of a thermal probe or radiofrequency due to the potential for excessive heat buildup.
Conclusion: A New Frontier in Shoulder Arthroscopy
Dry arthroscopy of the shoulder represents a valuable alternative to the traditional wet technique. By minimizing fluid use and working in a more physiological environment, it offers potential advantages in terms of anatomical preservation, reduced bleeding, and expanded surgical possibilities. While challenges remain, this technique holds promise for advancing the field of shoulder arthroscopy and improving patient outcomes. Further research and clinical experience will be crucial to fully define its role in the treatment of various shoulder pathologies. This “cowboy’s guide” offers a starting point for understanding and exploring this exciting new frontier.
