A Intermediate Evaluation and Management 1 Obtains focused history and performs physical examination provocative tests Speed and Yergasons tests O'Briens load compression test differential diagnosis and physical exam tests 2 Orders basic imaging studies radiographs AP true AP with active shoulder abduction Axillary lateral Scapular Y view 3 Prescribes non-operative treatment physical therapy anti-inflammatory medication cortisone injections in the subacromial space 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Provide basic post op management (phases of cuff repair rehab 1-3) postop: 2-3 week postoperative visit wound check remove sutures start active range of motion in all planes except for external rotation postop: 6 week postoperative visit start external rotation and abduction start strengthening 3 month postoperative visit start sports activities except for throwing B Advanced Evaluation and Management 1 Interpret basic imaging studies MRI labral tears arthritis C Preoperative H & P 1 Obtain history and perform physical exam history age gender smoker trauma physical exam check range of motion identify medical co-morbidities that might impact surgical treatment 2 Perform operative consent describe complications of surgery including infection stiffness RSD persistent tear
E Preoperative Plan 1 Radiographic templating 2 Execute surgical walkthrough describe steps of the procedure verbally to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Make sure tower working 30° arthroscope fluid pump system standard arthroscopic instruments suture passing devices suture retrieving devices knot tying devices arthroscopic shavers and burrs radiofrequency ablation wand suture anchors 2 Room setup and Equipment beach chair 3 Patient Positioning Place on beach chair<br /> pad any prominences of the extremities position the head and neck in neutral alignment ensure the entire scapula is free from the edge of the table place the arm place arm in articulated hydraulic arm holder G Portal Placement 1 Outline landmarks Outline the acromion, distal clavicle, coracoid process and portal placement 2 Place posterior portal mark portal 1 to 3 cm distal and 1 to 2 cm medial to the posterior lateral tip of the acromion make small skin incision place blunt trocar with the arm in 15° of abduction and 30° of forward flexion use lateral traction to avoid damage to the articular surface place the 30° arthroscope. make sure poitn Place anterior portal halfway between acromioclavicular joint and the lateral aspect of the coracoid pierce the anterior fibers of the deltoid and enter the joint in the interval between the supraspinatus and subscapularis 3 Place lateral portal place laterally in line with the mid clavicle and 2 to 3 cm lateral to its lateral edge 4 Place posterorlateral portal 1 cm distal to the posterolateral corner of the acromium 5 Place Neviaser portal superomedial portal bordered by the clavicle the acromioclavicular joint and the spine of the scapula H Diagnostic Arthroscopy 1 Visualize the anatomy articular cartridge of the humeral head and glenoid labrum biceps tendon inferior recess articular surface insertion of the subscapularis, supraspinatus, infraspinatus and teres minor 2 Establish anterior portal localize portal with an 18 gauge spinal needle placement place a seven minute millimeter cannula using the outside-in technique I Glenoid Preparation and Accessory Portal Placement 1 Identify the detachment identify the detachment by direct probing 2 Debride frayed or degenerative tissue use a 4.5 mm motorized shaver use a motorized burr to debride the superior glenoid to expose bleeding bone 3 Place portal place an accessory trans-rotator cuff portal using an outside in technique use a spinal needle to check that the trajectory of the suture anchor will at a 45 degree angle to the glenoid face J Suture Anchor Placement and Suture Management 1 Place the anchors place the suture anchor at a 45 degree angle to the glenoid face this angle ensures that the anchor is solid in the bone this suture anchor may be single or double loaded with nonabsorbable no 2 suture depending on the preference of the surgeon place the first suture anchor posteriorly and place the second anchor more anterior place the anchor in the same trajectory as the drill 2 Retrieve suture limb retrieve one limb of the suture through the anterior superior cannula with either a crochet hook or suture grasper retrieve the other limb with a crochet hook through the anterior inferior cannula K Suture Passage and Knot Tying 1 Pass sutures through margins of tear pass the suture through the anterosuperior cannula start at the posterior edge at the superior aspect of the tear and pass the tissue penetrator through the labrum for a right shoulder SLAP tear use a 45 degree left curved penetrator and for a left shoulder SLAP tear use a 45 degree right curved tissue penetrator insert an arthroscopic grasper and pass it through the anteriorinferior portal to grab the monofilament suture as it penetrates the labrum pull the free end through the anteroinferior cannula 2 Tie Knots tie a simple knot in the passing suture insert the free end of the suture anchor through the loop pull the suture gently through the anterosuperior portal so that both ends of the suture anchor are together out of the anterosuperior portal tie the suture using a sliding knot r a series of half stitches cut the excess suture using an arthrscopic suture cutter L Additional Anchor Placement 1 Place anchors repeat the above procedure until the biceps anchor is reattached to the superior glenoid be aware of an anterosuperior variant that can be incorrectly identified as a SLAP tear N Wound Closure 1 Irrigation, hemostasis, and drain irrigate the portals 2 Deep closure use 3-0 biosyn for closure 3 Superficial closure use 4-0 biosyn for skin 4 Dressing and immediate immobilization place sling
O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds wound care schedule follow up 2 outpatient PT place in a sling wear at all times except for hygiene R Complex Patient Care 1 Modifies and adjusts post operative rehabilitation plan as needed post-operative stiffness 2 Order and interpret advanced imaging studies MRI labral tears 3 Treats intra-operative and post operative complications irrigation and debridement for infection proper infection treatment infectious disease consultation