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Small-to-medium full-thickness rotator cuff repair - Arthroscopic

Planning

B

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
C

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 or statndard OR table for lateral decubitus position

3

Patient Positioning

  • Place on beach chair or lateral decubitus position
  • 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

Technique

D

Scope Insertion

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

3

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

4

Place lateral portal

  • place laterally in line with the mid clavicle and 2 to 3 cm lateral to its lateral edge

5

Place posterorlateral portal

  • 1 cm distal to the posterolateral corner of the acromium

6

Place Nevias portal

  • superomedial portal bordered by the clavicle the acromioclavicular joint and the spine of the scapula
E

Diagnostic Arthroscopy and Intra-articular Debridement

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

3

Debride tissues

  • place a 4.5 mm for radius shaver in anterior portal for intraarticular debridement
  • debride degenerative labral tears, synovitis and cartilage lesions
F

Subacromial Bursectomy +/- Acromioplasty

1

Move trocar

  • move the arthroscope to the subacromial space
  • slide the trocar under the acromium over the posterior rotator cuff
  • sweep under the acromium through the lateral gutter to break up adhesions

2

Identify the coracoacromial ligament

  • found on the anterior aspect of the subacromial space

3

Create a lateral working portal

  • localize portal with spinal needle through the deltoid
  • insert 8.25 mm threaded cannula into lateral portal

4

Perform bursectomy

  • use a 4.5 mm barrel shaped burr through the lateral portal
  • use the full radial shaver to perform a complete bursectomy
  • remove remaining bursa and soft tissue from the undersurface of the acromion with a radiofrequency ablation wand
  • examine the anterior aspect of the acromium and cc ligament for signs of impingement

5

Perform acromioplasty

  • partially resect the cc ligament with the ablation wand to expose the entire acromium
  • start the acromioplasty at the anterior lateral corner and remove 5 to 8 mm of bone
  • carry the resection medially to the AC joint
  • make the resection level by sweeping the burr from anterior to posterior
  • move the arthroscope to the lateral portal place and place burr in the posterior portal
  • sweep the bird from a medial to lateral direction
G

Cuff Mobilization, Preparation of Tendon and Tuberosity

1

Tendon Debridement

  • place the arthroscope in the posterolateral portal and the instruments in the lateral portal
  • debride the tendon with an arthroscopic basket resector or a full radius shaver
  • clear the remaining soft tissue with a radiofrequency ablation wand

2

Footprint Preparation

  • use shaver to remove soft tissue from the greater tuberosity
  • make sure to expose the cortical bone
H

Marginal Convergence Sutures

1

Pass sutures through margins of tear

  • use a sharp suture passing instrument loaded with a high tensile strength free suture through the anterior portal to penetrate the anterior leaf of the tear
  • use a second suture passing instrument from the posterior portal to penetrate the posterior leaf of the tear

2

Tie knot

  • pass the free suture from the anterior instrument to the posterior instrument
  • pull through the posterior portal
  • take both limbs of the suture and pass them through lateral portal to tie and complete the marginal convergence stitch
  • this is used and L reverse L and U-shaped tears to reduce the amount of strain on the tendon at the tuberosity repair and reduce the size of the tear
I

Anchor Placement, Suture Passage and Definitive Knots

1

Place anchors

  • place 2 or 3 medial anchors at the level of the anatomic neck
  • separate each anchor by 1 to 1.5 cm
  • make small stab incisions just off the lateral border of the acromion
  • place 2 or 3 medial anchors at the level of the anatomic neck

2

Pass sutures

  • pass sutures from the medial row of anchors through the tendon
  • start with the most anterior anchor
  • pass both strands of one suture through the anterior aspect of the tear in a horizontal mattress manner
  • pass sutures 1 cm medial to the lateral aspect of the tear
  • pass one strand of the second suture next to the most posterior strand o of the first suture
  • repeat steps for the posterior anchor of the medial row
  • pass two strands of one suture through the posterior aspect of the tear.
  • place one strand of the second suture anterior to the previously placed mattress suture and retrieve through the anterolateral portal
  • retrieve both strands of the posterior mattress stitch out of the lateral portal
  • tie arthroscopically and cut
  • tie the remaining strands that have been passed through the tendon together
  • tie oustide the shoulder through anterolateral portal
  • cut the tails and advance the knot into the shoulder
  • this is done by pulling on the opposite strands of the two sutures

3

Place a single lateral suture anchor

  • place anchor on the lateral aspect of the rotator cuff footprint on the greater tuberosity halfway between the medial anchors
  • retrieve one strand of one suture and pass it medial to the horizontal stitch between the anterior and posterior medial anchors
  • repeat step with second suture from lateral anchor

4

Tie knots

  • pull on the remaining medial sutures to tension the horizontal mattress stitch while the the lateral row sutures are tied
  • retrieve the remaining two strands of the medial row anchors out of the lateral portal and tie
J

Wound Closure, Confirm Repair and Address Intraoperative Complications

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

Patient Care

K

Preoperative H & P

1

Obtain history and perform physical exam

  • history
  • age
  • gender
  • smoker
  • trauma
  • night pain
  • physical exam
  • check range of motion
  • weakness of the extremity
  • inspect for atrophy
  • identify medical co-morbidities that might impact surgical treatment

2

Perform operative consent

  • describe complications of surgery including
  • infection
  • stiffness
  • RSD
  • retear
L

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain meds
  • wound care
  • schedule follow up
  • orders and interprets basic imaging studies
  • order postoperative radiographs of the shoulder to ensure appropriate implant placement

2

outpatient PT

  • place in a sling
  • for small and medium tears
  • remove for elbow range of motion exercises three or four times today a day
  • for large tears
  • do not remove sling and no motion for 6 weeks
M

Outpatient Evaluation and Management

1

Obtains focused history and performs physical examination

  • provocative tests
  • Neer/Hawkins
  • O'Briens
  • lag signs
  • pseudoparalysis
  • lift-off
  • belly press
  • scapular dyskinesia
  • concomitant and associated orthopaedic injuries
  • differential diagnosis and physical exam tests

2

Orders basic imaging studies

  • radiographs
  • AP
  • true AP with active shoulder abduction
  • Axillary lateral
  • Scapular Y view
  • with chronic tears sclerotic and cystic changes of the greater tuberosity are found
  • with large tears proximal humerus migration can be found on AP and true AP views
  • look for narrowing of the acromial humeral interval on AP to identify a large tear

3

Prescribes non-operative treatment

  • physical therapy
  • stretching, rotator cuff and scapular stabilizer strengthening exercises
  • 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
  • rehabilitation for small or medium tears
  • remain in a sling for six weeks with no shoulder motion allowed
  • remove sling at 6 weeks
  • start passive and active assisted range of motion exercises including forward elevation in the scapular plane, external rotation in full abduction, pendulum and pulley exercises
  • limit internal rotation and shoulder extension
  • no lifting, pushing or overhead activity
  • rehabilitation for large tears
  • remain in sling with no motion for six weeks
  • at six weeks remove sling and lift arm to shoulder height only
  • at six weeks use shoulder CPM device to regain forward elevation in the scapular plane
  • continue CPM until three months postop
  • diagnose and management of early complications
  • 3 month postoperative visit
  • for small and medium tears start strengthening exercises
  • isometric exercises progress to isotonic exercises
  • with a stretching program throughout
  • for large tears
  • initiate passive and active motion
  • strengthening
  • return to sports and unrestricted activity at six months
  • diagnosis and management of late complications
  • 4-6 month postoperative visit
  • for small and medium tears return to sports and full unrestricted activity at 4 to 5 months
  • for large tears return to activity at 6 months
N

Advanced Evaluation and Management

1

Interpret basic imaging studies

  • radiographs
  • proximal humeral migration on xray
  • MRI
  • tear size
  • muscle atrophy
  • labral tears
  • arthritis
  • subscapularis tears
  • evaluates both the tendon and muscle quality
  • full thickness tears show increased signal intensity at the tendon insertion on T-2 weighted images
O

Complex Patient Care

1

Modifies and adjusts post operative rehabilitation plan as needed

  • modify for massive cuff repairs
  • post-operative stiffness

2

Order and interpret advanced imaging studies

  • MRI
  • evaluates both the tendon and muscle quality
  • tear size
  • muscle atrophy
  • labral tears
  • arthritis
  • subscapularis tears
  • full thickness tears show increased signal intensity at the tendon insertion on T-2 weighted images

3

Treats intra-operative and post operative complications

  • irrigation and debridement for infection
  • proper infection treatment
  • infectious disease consultation
 

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