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Subscapularis and Rotator Cuff Repair- Arthroscopic

Planning

B

Preoperative Plan

1

Radiographic evaluation (x-ray and MRI)

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 in 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 or other suitable traction device
  • supervises appropriate surgical prep and draping of the field.

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 the scope sheath with a blunt trocar into the glenohumeral joint with the arm in 70° of abduction and 10° of forward flexion with approximately 10# of traction.
  • insert the 30° arthroscope.

3

Place anterior portal

  • create either an anterior mid-glenoid portal or an anterior superior rotator interval portal. Use a spinal needle either through the upper portion of the rotator interval (just anterior to the biceps) or pass directly through the anterior portion of any rotator cuff tear.) to allow viewing of steps 11-15.
  • pierce the anterior fibers of the deltoid and enter the joint in the interval between the supraspinatus and subscapularis
E

Diagnostic Arthroscopy

1

Visualize the anatomy from the posterior portal

  • 1. Biceps tendon and superior labrum
  • 2. posterior labrum and posterior capsule
  • 3. inferior capsule and inferior portion of the humeral head
  • 4. Glenoid cartilage
  • 5. Rotator cuff articular surface
  • 6. Posterior cuff attachment into the humerus and adjacent bare area
  • 7. Weight bearing articular surface of the humeral head
  • 8. Anterior superior labrum, superior glenohumeral ligament and rotator interval
  • 9.Subscapularis tendon and middle glenohumeral ligament
  • 10. Anterior inferior labrum and inferior glenohumeral ligments

2

Visualize anatomy from the anterior portal

  • 11. Posterior labrum and posterior capsule
  • 12. Anterior inferior labrum and ligaments
  • 13.Anterior capsule insertion into the anterior humerus
  • 14. Subscapularis recess
  • 15 Anterior surface of the humerus, biceps tunnel and subscapularis insertion

3

Insert an anterior-superior cannula high in the rotator interval

  • use a spinal needle either through the upper portion of the rotator interval (just anterior to the biceps) or pass directly through the anterior portion of any rotator cuff tear.
  • insert an 6 mm operating cannula in this portal

4

Insert the anterior mid-glenoid operating cannula

  • place a seven millimeter operating cannula into the rotator interval 2 cm lateral to the glenoid in the area of the upper border of the subscapularis tendon
  • place a 5.5 mm full radius shaver in anterior portal for intraarticular debridement
  • debride degenerative labral tears, synovitis and cartilage lesions
F

Glenohumeral Debridement

1

Debrided the rotator cuff tendon and footprint

  • place the shaver in the posterior and anterior portal
  • debride the ragged surface of the underside of the rotator cuff
  • remove torn tissue from the footprint of the greater tuberosity
G

Subscapularis Repair

1

Debride subscapularis footprint

  • identify the upper lateral border of the subscapularis by visualizing the rolled edge anterior to the glenoid. Use a grasper tool to test for mobility by pulling it up to the humerus.
  • use a motorized shaver and a curette to debride soft tissue off the footprint on the anterior surface of the humeral head

2

Mobilize the subscapularis tendon

  • release the capsule anterior to the subscapularis if it is restricting reduction of the tendon to the prepared bone.
  • use a liberator elevator or electrosurgical tool to carefully and avoid damage to the axillary nerve and the labrum.

3

Prepare the subscapularis tendon

  • use the shaver to debride loose soft tissue from the torn stump of the subscapularis tendon
  • open the rotator interval by removing capsule tissue in this area and allow visualization of the coraco-acromial ligament

4

Place the first anchor

  • place the first triple-loaded suture anchor into the prepared humerus neck in a position that ensures that the subscapularis can be attached without significant tension.t

5

Suture management

  • remove 2 of the 3 sutures pairs into the superior cannula with a crochet hook.
  • place all 4 sutures outside the cannula using switching stick technique
  • retrieve the more medial of the remaining sutures into the anterior superior cannula with a crochet hook.
  • Pass an appropriately curved suture hook through a healthy portion of the most inferior edge of the subscapularis tendon.
  • Pass a suture shuttle through the tendon and retrieve it into the anterior superior cannula with a grasper.
  • load the suture into the shuttle and carry it back through the tendon and into and anterior mid-glenoid cannula.

6

Tie sutures

  • tie the 2 ends of the suture together
  • this should close the lower portion of the subscapularis

7

Pass the second and third sutures

  • pass the second and third suture pairs in a similar fashion spacing them 5 mm apart.
  • tie the suture with a sliding-locking knot on the anterior surface of the anterior capsule and subscapularis.
  • If the quality of the tendon is poor, especially at the upper end, pass the same suture a second time again using a shuttle to create an "Italian loop" and tie with a Modified Revo knot.
H

Bursoscopy and Subacromial Decompression

1

Reposition the arm

  • place the arm in 10 degrees if abduction and 5 degrees of forward flexion
  • place 15 lbs of traction to support the arm

2

Reposition instruments

  • place the scope in the posterior bursal portal
  • place a cannula in the anterior bursal portal
  • place the arm in slight adduction

3

Prepare for subacromial decompression

  • change the irrigant to glycine
  • place and use the electrosurgical tool through the lateral portal

4

Debride soft tissue

  • morselize the soft tissues including the bursa and coracoacromial ligament from under the anterior two thirds of the acromial bone

5

Perform bony decompression

  • begin the resection at the lateral edge of the acromion from the anterior corner to the mid acromial area
  • remove approximately 5mm of bone

6

Reposition intruments

  • place the scope in the lateral portal and the shaver in the posterior portal to complete the resection

7

Smooth the acromion

  • smooth the entire undersurface of the anterior half of the acromion in a gently sloping fashion until 5 mm is removed

8

Remove the facets

  • remove the undersurface of the acromial facet
  • remove the undersurface of the inferior facet
I

Rotator Cuff Repair

1

Prepare the rotator cuff tendon

  • debride the edges of the cuff to healthy tissue

2

Prepare the greater tuberosity

  • use the motorized shaver to lightly decorticate the bony bed below the resting edge of the cuff

3

Create marrow vents

  • create multiple bone marrow vents in the greater tuberosity using a 1.5 mm punch

4

Assess the placement of the suture anchors

  • use a spinal needle to assess the proper angle for inserting the suture anchor

5

Place the first anchor

  • place the first anchor through a puncture wound lateral to the acromion
  • screw the anchor down through the deltoid
  • place the tip of the anchor in the pilot hole that is a few mm lateral from the edge of the cartilage

6

Set the anchor

  • screw the anchor into bone angeling it 30º under the subchondral bone.
  • seat the anchor 3 mm below the cortical surface

7

Pass the sutures

  • pass the sutures through the cuff using a curved suture needle and a shuttle relay
  • store sutures in the suture saver
  • place the second anchor approximately 1.2 cm anterior from the first
  • pass and store the sutures in the suture saver
  • withdraw the sutures in pairs out of the lateral cannula

8

Tie sutures

  • tie the sutures using SMC knots
J

Wound Closure

1

Irrigation and hemostasis

  • copiously irrigate the wound

2

Superficial closure

  • close with a singular subcuticular 4-0 monocry suture
  • apply steristrips
  • place prowick sponges that have been primed with liquid betadine over the incisions

3

Immobilization

  • Place the patient in a sling in 15 degrees of external rotation

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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