**10. Conclusions**

44 Modern Arthroscopy

Routinely, the Latarjet procedure is performed through a standard deltopectoral approach. However, an all-arthroscopic alternative has been advocated recently as a consequence of the success of the open procedure and the advancements in arthroscopic instrumentation and techniques. This procedure offers the potential advantages of more accurate graft placement, management of associated joint pathology, such as bidirectional shoulder instability, ease of technique conversion, and faster rehabilitation with decreased joint stiffness and better cosmetic result (Lafosse et al, 2010). Although there is inevitably a steep learning curve, excellent results with good graft positioning and minimal complications

Fig. 12. The Latarjet procedure. Notice how the coracoid process graft supplements the articular surface of the original "inverted pear" glenoid to increase its anteroposterior

diameter.

have also been reported with arthroscopic Latarjet repair.

Arthroscopic treatment of shoulder instability has evolved considerably over the past decades. A detailed patient history and thorough physical examination are still considered the milestones for successful treatment planning. Advanced MRI imaging has offered a more accurate diagnosis and improved understanding of the pathology to be addressed. Presently, suture anchor stabilization is the operation that best duplicates the time-tested open procedure. Patient selection criteria, improved surgical techniques and implants available have contributed to the enhancement of clinical and functional outcomes to the point that arthroscopic treatment is considered nowadays the standard of care. However, arthroscopic techniques are demanding and there is a steep learning curve. Bone loss issues, including Hill-Sachs and glenoid rim lesions, remain a concern and a challenge for arthroscopists to manage.

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**3** 

*Spain* 

Diego Benítez and Luis M. Torres

*Department of Anesthesia, University Hospital Puerta del Mar, Cátedra del Dolor Fundación Grunenthal-Universidad de Cádiz* 

**Anesthesia for Arthroscopic Shoulder Surgery** 

Arthroscopic shoulder surgery is a minimally invasive technique that effectively treats certain diseases and injuries of the shoulder joint. Indeed, new lesions and surgical

Controlling post-operative pain in shoulder surgery facilitates early mobilization and fast functional recovery, allowing pain-free muscle contraction. Tissue injury due to the surgical intervention results in the release of many chemical mediators that activate and increase the excitability of nociceptors, producing intra- and post-operative hyperalgesia. Local anesthesia can be used more frequently for less aggressive surgical techniques, particularly

It is essential to be familiar with the anatomy of the region to be anesthetized in order to minimize the potential risks and recognize them when they occur. The upper limb is innervated by the arms of the cervical spinal nerves (C5-C8) and part of the ventral branch of T1, although anatomical variations may exist. All these sensory, motor and vegetative

The block of the brachial plexus was first developed in 1884, when Halstead injected cocaine into the exposed roots of the brachial plexus (1). However, it was not until 1911 that Hirschel and Kulenkampff described the percutaneous brachial plexus block first developing the axillary technique and then, the supraclavicular route (2,3). In 1919, Mulley developed a technique aimed at preventing pneumothorax by employing interscalenic approach to the brachial plexus (4). The modern interscalenic approach was perfected by Winnie, using the transverse processes of the 6th cervical vertebra (5) as a reference for

Anesthetic options for shoulder arthroscopic surgery include: general anesthesia, regional anesthesia with or without sedation, and a combination of both general and regional anaesthesia. Regional anesthesia offers many advantages over general anesthesia for arthroscopic shoulder surgery. The most notable advantage is the ability to control perioperative pain by proximally blocking the brachial plexus (supraclavicular approaches). The "Preemptive" analgesia afforded by the blockade and the excellent analgesic conditions can overt the need for intraoperative opioid administration. The patients' perception of pain-free surgery represents a further advantage of this approach. Together, this facilitates earlier hospital discharge with the attendant reduction in the economic cost of the procedure

nerve fibers form an "anastomotic complex of fibers", known as the brachial plexus.

techniques for their treatment have also been discovered by using this approach.

in limb surgery, both for intra-operative and post-operative pain.

**1. Introduction** 

needle insertion.

(6,7).

