Preoperative Patient Care A 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 B 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 C 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 Operative Techniques E Preoperative Plan 1 Radiographic templating identify Pathology on AP Radiographs 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 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 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 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 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 I 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 J 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 K 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 L 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 N 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 Postoperative Patient Care O 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 R 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
A 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 B 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 C 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
E Preoperative Plan 1 Radiographic templating identify Pathology on AP Radiographs 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 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 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 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 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 I 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 J 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 K 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 L 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 N 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
O 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 R 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