A Outpatient Evaluation and Management 1 Obtain focused history and performs physical examination Perform provocative tests Create differential diagnosis by physical exam tests 2 Order basic imaging studies Order radiographs AP true AP with active shoulder abduction Axillary lateral Scapular Y view 3 Prescribes non-operative treatment Prescribe physical therapy stretching, rotator cuff and scapular stabilizer strengthening exercises Prescribe anti-inflammatory medication 4 Makes informed decision to proceed with operative treatment Document failure of nonoperative management Describe accepted indications and contraindications for surgical intervention 5 Provide basic post op management (phases of bankart rehab 1-3) Perform an appropriate 2-3 week postoperative visit check the wound remove sutures issue explicit orders to the therapist to avoid forceful external rotation manipulation in abduction for the first 3 months at weeks 6 to 12 weeks instigate a formal physical therapy program if progress is slow and external rotation is less than 35 degrees start strengthening exercises after full ROM is achieved diagnose and management of early complications<br /> Perform an appropriate 4 month postoperative visit advance to a throwing rehabilitation program Perform an appropriate 6 month postoperative visit release to full activities including contact sports provided that strength and motion are near normal and instability symptoms are absent. B Advanced Evaluation and Management 1 Interpret basic imaging studies Interpret radiographs Interpret MRI labral tears Hill Sachs lesions arthritis C Preoperative H & P 1 Obtain history and perform physical exam Obtain history age gender smoker trauma number of dislocation/subluxation events Perform 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 recurrent instability postoperative glenohumeral noise or squeaking can occur if the knots are captured in the GH joint loss of external rotation from overtightening rupture of the repair can occur with aggressive early activities injury to the axillary nerve
D Shoulder Workstation Simulation 1 1 Simulation Set Up Disclosure: Orthobullets does not promote any one industry product. While we use Sawbone®, FAST®, and Magnetiscope® in this learning module, many different simulation systems may be used to complete this simulation. Set up Sawbone® rotator cuff component in the mounting bracket of the FAST® Arthroscopy Module. Install and mount the Magnetiscope® camera and open QuickTime player to view simulation on computer. Adjust the camera so that the anterior-inferior labrum is clearly visible in the center of the screen as it would be if you were viewing it from the anterior superior portal in a patient. Place two 7mm docking cannulas, one in the posterior mid-glenoid and one in the anterior mid-glenoid portals of the FAST® simulator. Check the instrumentation you need for the procedure is present. "tommy bar" which is a large Steinmann pin with the end blunted preferably locked into a screwdriver handle liberator elevator double loaded suture anchor crochet hook Arthroscopic grasper suture passers(various choices depending on desired product usage) knot pusher 4 hemostat clamps knot cutting device 2 Mobilize the labrum Insert a liberator elevator through the anterior mid-glenoid portal and elevate the labrum off of the glenoid. Once the edge of the labrum is free, use the "tommy bar" to pry the labrum and capsule completely off the glenoid neck so that it is free floating with no remaining scar to the subscapularis muscle or glenoid. 3 Place suture anchor Create a pilot hole 1.5 mm onto the face of the glenoid at the 5:30 position for the inferior-most anchor by using the appropriate drill through a curved guide that is passed through the anterior mid-glenoid portal the drill guide should be curved to direct the drill toward the center of the glenoid to avoid penetrating the inferior cortex Screw or pound in a double-loaded suture anchor until it is seated a few mm below the glenoid subchondral surface Remove the anchor driver by pulling or tapping straight back taking care not to toggle it Retrieve one strand of suture from the anchor into the posterior cannula using a crochet hook 4 Passing Sutures Insert a 45º or 60º curved suture hook loaded with a shuttle device into the anterior mid-glenoid portal and pierce the anterior inferior capsule tissue 1 to 2 cm away from the labrum and 1-2 cm inferior to the level of the anchor create a “pinch tuck” stitch in the tissue by passing the tip of the needle through a pinch of the capsule and then under the labrum 5 mm below the level of the anchor Roll the wheel on the suture hook handle to send the shuttle into the joint Grasp the tip of the shuttle with an arthroscopic grasper inserted through the posterior cannula and retrieve it out the posterior cannula Outside the posterior mid-glenoid portal load the suture in the eyelet of the shuttle and carry it back through the joint, under the labrum and through the capsule by pulling back on the anterior end of the shuttle the suture strand that was pulled with the shuttle will be designated as the first post suture for tying Retrieve the other limb of the suture that was passed with a crochet hook into the anterior mid-glenoid portal Retrieve the other two sutures (those of a different color from the one previously passed) into the posterior cannula to avoid tangling when tying the first suture 5 Suture tying Tie the first two sutures together using a sliding-locking knot followed by three half hitches alternating the post suture to ensure a secure knot Slide knot cutting device over sutures and cut them appropriately near the knot 6 Passing second suture Retrieve one limb of the remaining suture into the anterior mid-glenoid cannula Pass the second strand of suture through the capsule and under the labrum this time exiting 5 mm above the anchor Identify which of the two sutures is located on the capsular side and use it as the post Tie the second suture above the anchor ensuring that the knot is located on the capsule side away from the cartilage 7 Place a second anchor A second anchor can be placed 1.5-2 cm above the first one, usually just below the anterior mid-glenoid notch Pass both sutures from this anchor through a fold of capsule and under the labrum one below and one above the anchor site Tie sutures individually E Preoperative Plan 1 1 Perform radiographic and MRI evaluation 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 P 1 Make sure tower is working and equipment is present Confirm tower visualization and irrigation system is working and equipment is present including 30° arthroscope fluid pump system Confirm presence of standard arthroscopic instruments including Liberator elevator "Tommy bar" suture passing devices suture retrieving devices knot tying devices 4.2mm arthroscopic shaver double-loaded suture anchors 2 Setup Room and Equipment 3 Examine patient under anesthesia Assess range of motion in all planes Load and shift procedure in 90 degrees of abduction and neutral rotation Repeat load and shift in positions of increasing external rotation, shifting both anteriorly and inferiorly Test for sulcus sign by pulling inferiorly on the arm and evaluating the lateral acromion/humeral head space Perform a posterior jerk test 4 Position Patient Position patient in lateral decubitus position Pad bony prominences Position the head and neck in neutral alignment support the head with a foam head cradle Protect the eyes with tape Place an axillary roll under the upper chest to protect the lower shoulder and axilla Ensure the entire scapula is free from the edge of the table Support the arm in 70º of abduction and 10º of flexion using a foam shoulder traction sleeve in this position the inferior capsule is not completely relaxed, mitigating the risk of inadvertently gathering too much capsule in the axillary recess during the plication procedure, which would result in loss of abduction the view of the capsule in the inferior recess can be improved during the operation by having an assistant place a hand on the medial side of the arm midway between the axilla and the elbow and gently translating the humeral head in a superior direction. rotation during this maneuver can improve the view even more. Pearls Procedure can be done in Beach chair or lateral decubitus position, and is dependent on surgeon preference. G Scope Insertion 1 1 Outline landmarks Outline the acromion, distal clavicle, coracoid process and portal placement 2 Establish posterior mid-glenoid portal Mark the portal 1 to 3 cm distal and 1 to 2 cm medial to the posterior lateral tip of the acromion make a 4mm skin incision Insert the scope sheath with a taper tip trocar into the incision and enter the joint use lateral traction to avoid damage to the articular surface Insert the 30° arthroscope into the scope sheath 3 Establish anterior superior portal Place skin incision about 1 cm off the anterior lateral corner of the acromion. Use a spinal needle to localize position. Pierce the anterior fibers of the deltoid and enter the joint in the rotator interval directly behind the biceps tendon Make a small skin incision and insert a smooth operating cannula fitted with a taper-tip obturator H Diagnostic Arthroscopy 1 P P 1 Perform the first 10 points of the 15-point exam Visualize the following anatomic structures from the posterior portal: biceps tendon and biceps anchor grasp the biceps tendon laterally and pull it into the joint to evaluate the portion that is located in the biceps groove if the superior labrum is loose or traumatized palpate it with a nerve hook to determine if the biceps anchor is intact posterior labrum and posterior capsular pouch inferior capsular pouch and inferior aspect of the humeral head (? osteophyte on the humeral head) glenoid articular cartilage articular surface of the rotator cuff and rotator cuff crescent posterior rotator cuff attachment and bare area of the humeral head (? Hill-Sachs lesion) humeral head weight bearing articular cartilage surface anterior superior labrum and rotator interval subscapularis tendon and middle gleno-humeral ligament anterior-Inferior labrum and ligaments Pearls Identify the anatomy in a step-wise manner to avoid overlooking any pathology Consider documenting all 15 steps of anatomy with photos or video 2 Perform the final 5 points of the 15-point exam Insert the scope in the anterior portal and visualize the following structures: posterior labrum and posterior inferior capsule posterior superior capsule and posterior rotator cuff tendon anterior inferior labrum and ligaments subscapularis tendon and subscapularis recess medial to the glenoid anterior surface of the humeral head and subscapularis attachmen 3 Evaluate the Hill Sachs lesion Evaluate the size of the lesion Determine if the Hill Sach lesion engages. 4 Establish anterior mid-glenoid portal Localize anterior mid-glenoid portal with an 18 gauge spinal needle this portal should be placed just superior to the subscapularis tendon Place a 7 mm docking cannula using an outside-in technique Pearls Make sure this portal is positioned so that it can be used to place an anchor in the inferior glenoid Pitfalls If this portal is too high, the drill may skive inferiorly or the anchor could penetrate the inferior glenoid cortex I Labrum Mobilization and Glenoid Debridement 1 P P 1 Mobilize the labrum Mobilize the anterior labrum and capsule completely from the neck of the glenoid using a liberator, elevator knife, the "Tommy bar" and shaver Free the tissues down to the 6 o’clock position Test the mobility of the anterior tissue by grasping the labral edge with a pincer tool and advancing it to the edge of the articular surface. if it floats freely to the surface, the mobilization is complete if the tissues are still tight, continue to work the tissues with a 1/4inch Steinmann pin or Tommy bar as a lever until they are free to move into position up onto the cartilage surface Pearls It is critical to release all scar tissue so that the capsule/labrum can be easily repositioned to the edge of the cartilage Pitfalls Take care not to injure the labrum with the liberator elevator during mobilization 2 Debride the glenoid Debride the anterior edge of the glenoid removing frayed tissues this gives a clear view Lightly decorticate the glenoid using a rasp or shaver- do not remove bone Debride degenerative labral tears, synovitis and cartilage lesions Pearls Debriding the glenoid rim creates a healthy bleeding bed to promote labral healing J Anchor Placement for Bankart Repair 1 P P 1 Create pilot hole Create the first pilot hole for the inferior-most anchor by inserting the appropriate anchor drill down the AMGP and place the tip 1.5 mm on the face of the articular cartilage of the glenoid around the 5 -5:30 o’clock position. the drill guide should be curved to direct the drill toward the center of the glenoid Pearls Start the drill hole on the edge of the articular cartilage to ensure the labrum is advanced Pitfalls use a curved drill guide to avoid penetrating the inferior cortex and potentially injuring the axillary nerve 2 Insert anchor Insert the first 2.8 mm soft fabric mini anchor loaded with two strands of #2 polyethylene suture into the drill guide Impact it into the pilot hole Seat it by pulling back on the sutures Remove the anchor driver by pulling or tapping straight back Retrieve one strand of suture from the anchor into the posterior cannula using a crochet hook Pearls Be sure that the horizontal seating line is buried so that the anchor is at least 2 mm below the subchondral bone Pitfalls Take care not to toggle the anchor when removing the driver as this can loosen it and lead to anchor pullout 3 Shuttle the suture Insert a 45º or 60º curved suture hook loaded with a shuttle device into the AMGP and pierce the anterior inferior capsule tissue 1 to 2 cm away from the labrum and 1 -2 cm inferior to the level of the anchor and then under the labrum 5 mm below the level of the anchor if the capsule is patulous, create a “pinch tuck” stitch in the tissue by passing the tip of the needle through a pinch of the capsule and then completely under the labrum Roll the wheel on the suture hook handle to send the shuttle into the joint Grasp the tip of the shuttle with a miniature clamp and retrieve it out the posterior cannula Carefully observe the path of the shuttle to ensure that it does not trap any of the other sutures stored outside the cannula Outside the PMP load the suture in the eyelet of the shuttle and carry it back through the joint, under the labrum and through the capsule by pulling back on the anterior end of the shuttle Retrieve the other limb of the suture that was passed with a crochet hook into the anterior mid-glenoid portal Retrieve the other two sutures (those of a different color from the one previously passed) into the posterior cannula to avoid tangling when tying the first suture Pearls the suture strand that was pulled with the shuttle will be designated as the first post suture for tying Pitfalls If the needle is not inserted 1-2 cm below the anchor the labrum and capsule will not be adequately advanced K Suture Tying and Second Anchor Placement 1 P P 1 Tie sutures Tie the first two sutures together using a sliding-locking knot followed by three half hitches alternating the post suture to ensure a secure knot retrieve one limb of the remaining suture into the AMG cannula Pass the second strand of suture through the capsule and under the labrum this time exiting 5 mm above the anchor Use a pinch-tuck stitch if the capsule is patulous Identify which of the two sutures is located on the capsular side and use it as the post tie the second suture above the anchor, plicating the capsule and seating the labrum to the prepared bone of the glenoid Pearls Be certain that the initial "post" suture is the one passing through the capsule away from the cartilage 2 Place second anchor Drill the second anchor hole 1.5-2 cm above the first one, usually just below the anterior mid-glenoid notch Insert the second anchor and pull on the sutures to seat it tightly on occasion it is necessary to add a third anchor to complete the repair be careful not to close a normal sublabral hole or a Buford Complex Take both sutures from this anchor and pass through a fold of capsule and under the labrum Tie sutures individually after they are passed Pitfalls Be careful to aim the drill in a direction to avoid damaging the first anchor or the articular cartilage N Wound Closure 1 1 Close the incisions with a single subcuticular stitch Use 4-0 monocryl for closure 2 Apply steri strips 3 Place dressings Place surgical sponges that are primed with liquid betadine solution over the incisions Place and wrap surgical dressings over the incision Cut the arm portion of the wrap to relieve pressure around the axilla and upper humerus 4 Place sling Support the patients arm in a prefitted sling in 15 degrees external rotation and slight abduction
O Perioperative Outpatient Management 1 Discharges patient appropriately Prescribe appropriate pain meds Discuss wound care Schedule follow up 2 Order and interpret basic imaging studies Order postoperative radiographs of the shoulder to ensure appropriate implant placement and glenohumeral position 3 Arrange initial outpatient PT Encourage active elbow, wrist, and hand exercises the first day after surgery Begin progressive gentle pendulum motion, isometric internal and external rotation exercises, and assisted forward elevation using a pulley after 7 to 10 days R Complex Patient Care 1 Modifies and adjusts post operative rehabilitation plan as needed Identify post-operative stiffness 2 Order and interpret advanced imaging studies Interpret MRI 3 Treats intra-operative and post operative complications Perform irrigation and debridement for infection Perform proper infection treatment Consult infectious disease