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Shoulder Arthroscopy - Subacromial Bursectomy:

- Discussion:
see arthroscopic rotator cuff repair
   - basic science:
         - Vascular endothelial growth factor 121 and 165 in subacromial bursa are involved in shoulder joint
            contracture in type II diabetics with RC disease.
         - The molecular pathophysiology of subacromial bursitis in rotator cuff disease.
         - Proinflammatory cytokines and metalloproteases are expressed in the subacromial bursa in patients
           with rotator cuff disease.
         - Stromal cell-derived factor 1 (SDF-1, CXCL12) is increased in subacromial bursitis and downregulated
            by steroid and NSAIDS.
         - Increased IL-1beta expression and myofibroblast recruitment in subacromial bursa is associated with
            rotator cuff lesions with shoulder stiffness.
         - Interleukin-1-induced glenohumeral synovitis and shoulder pain in rotator cuff diseases.

- Surgical Considerations:
   - note that the subacromial bursa is an anterior structure;
   - it is located from the anterior one half to one third of the acromion to just medial to A-C joint to 1 to 2 cm
 anterior to acromion and 2.5 cm laterally;
   - posterior busrsal wall is thick posteriorly (called posterior bursal curtain))
                - this posterior bursal curtain frequently “closes” as the scope is backed posteriorly to get a larger field;
                - it may be necessary to resect a portion of this structure to visualize the entire arch;
   - technical considerations (see acromioplasty)
   - when introducing instruments into the subacromial bursa, use the blunt trochar sheath is lyse adhesions from the undersurface of the acromion and
                the lateral part of the deltoid;
   - OR descriptions bursal proliferation and inflammation, hemorrhaging in CA ligament, hypertrophy and fraying of CA ligament, acromial spur formation;
   - bursa is sometimes debrided after the acromioplasty, since it tends to bleed more (disrupting the case);
                - take special when debriding around the AC joint since bleeding is especially troublesome;
   - rotate the arm internally and externally to expose different parts of the bursa;
   - downward traction generally increases the working space available for the subacromial space. 
   - use of a radiofrequency device before a motorized shaver is used for bursectomy can help to minimize bleeding;
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