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SLAP repair

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

3

Patient Positioning

  • Place on beach chair
  • 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

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
E

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
F

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
G

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
H

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
I

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
J

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

Patient Care

K

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
L

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
M

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
N

Advanced Evaluation and Management

1

Interpret basic imaging studies

  • MRI
  • labral tears
  • arthritis
O

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
 

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