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Preoperative Patient Care
Operative Techniques
D

Simulation

1

Cadaveric demonstration of surgical approach and therapeutic skill

2

Sawbones demonstration of proper instrumentation

E

Preoperative Plan

1

Radiographic templating

2

Perform ligamentous exam under anesthesia

3

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

  • standard OR table for lateral decubitus position

3

Patient Positioning

  • place patient in the lateral decubitus position
  • pad any prominences of the extremities
  • position the head and neck in neutral alignment
  • support the head with a foam head cradle
  • protect the eyes with tape
  • place an axillary role under the upper chest to protect the lower shoulder and axilla
  • ensure the entire scapula is free from the edge of the table place the arm
  • support the arm with the Meisel mitten in the arthroscopy position with 10 pounds of traction
  • prep and drape the arm in the usual fashion for shoulder arthroscopy
G

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 (optional)

  • 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
H

15 Point Arthroscopic Exam

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

Glenohumeral Debridement

1

Debride the underside of the rotator cuff

  • use the shaver through both the posterior and anterior portal to debride the ragged surface of the underside of the rotator cuff

2

Prepare the footprint of the greater tuberosity

  • remove the torn tissue from the footprint of the greater tuberosity
J

Bursoscopy

1

Maneuver the arm

  • maneuver the arm to the bursoscopy position
  • use 15 pounds of weight to support the arm in 10 degrees of abduction and 5 degrees of forward flexion

2

Place the scope in the posterior bursal portal

  • place a cannula in the anterior bursal portal

3

Evaluate the bursa

K

Subacromial Decompression

1

Change the irrigant to glycine

2

Place the electrosurgical cautery tool in the lateral cannula

3

Morselize the soft tissue

  • use the cautery tool to morselize the soft tissues including the bursa and coracoacromial ligament from under the anterior 2/3 of the acrominal bone

4

Remove debris

  • use a high speed shaver to remove the debris
  • remove overgrown and degenerative bursal tissue

5

Perform a bony decompression

  • use a high speed shaver to then perform the bony decompression by beginning a resection of the lateral edge of the acromion on from the anterior corner to the mid acromial area
  • place the scope in the lateral portal and the shaver in the posterior portal to complete the resection
  • If necessary smooth the entire undersurface of the anterior half of the acromion in a sloping fashion until approximately 8 mm is removed from the anterior edge

6

Evaluate the undersurface of the acromial facet

7

Evaluate the undersurface of the inferior facet

L

Cuff Repair

1

Debride the edge of the cuff back to healthy tissue

2

Prepare the bony bed

  • use a morselized 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 tuberosity using a 1.5 mm punch

4

Position suture anchors

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

5

Insert the anchors

  • insert the first Revo anchor through a puncture wound lateral to the acromion and screwed down through the deltoid muscle
  • place the tip of the anchor in the pilot hole a few mm lateral from the edge of the cartilage
  • screw the anchor into the bone so that it is seated 3 mm below the cortical surface
  • pass the sutures through the cuff using a curved suture needle and a suture relay
  • place the sutures in the suture shaver
  • triple load the each anchor with polyethylene sutures
  • place a second suture 1.5 cm anterior to the first
  • pass all three sutures using the shuttle technique through the edge of the cuff

6

Close the cuff lamina with sutures

  • after all sutures are passed, withdraw the sutures in pairs out of the lateral cannula

7

Tie the sutures

  • tie the sutures using SMC knots
  • cut the suture to create suture tails that are 2mm

8

Assess the repair

  • use a palpating probe to examine the repair
  • turn the fluid pump off to observe bone marrow flow
N

Wound Closure

1

Irrigation, hemostasis, and drain

  • withdraw the instruments
  • irrigate the portals

2

Close the incisions with a single subcuticular stitch

  • use 4-0 monocryl suture

3

Apply steristrips

4

Place dressings

  • place prowicks sponges that are primed with liquid betadine solution over the incisions
  • place and wrap Prowick dressings over the incision
  • cut the arm portion of the wrap to relieve pressure

5

Place sling

  • support the patients arm in an Ultrasling 15 degrees in an ER brace
Postoperative Patient Care
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