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Preoperative Patient Care
Operative Techniques

Preoperative Plan


Radiographic templating


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

Room Preparation


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


Room setup and Equipment

  • beach chair


Patient Positioning

  • Place on beach chair<br />
  • 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

Portal Placement


Outline landmarks

  • Outline the acromion, distal clavicle, coracoid process and portal placement


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


Place lateral portal

  • place laterally in line with the mid clavicle and 2 to 3 cm lateral to its lateral edge


Place posterorlateral portal

  • 1 cm distal to the posterolateral corner of the acromium


Place Neviaser portal

  • superomedial portal bordered by the clavicle the acromioclavicular joint and the spine of the scapula

Diagnostic Arthroscopy


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


Establish anterior portal

  • localize portal with an 18 gauge spinal needle placement
  • place a seven minute millimeter cannula using the outside-in technique

Glenoid Preparation and Accessory Portal Placement


Identify the detachment

  • identify the detachment by direct probing


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


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

Suture Anchor Placement and Suture Management


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


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

Suture Passage and Knot Tying


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


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

Additional Anchor Placement


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

Wound Closure


Irrigation, hemostasis, and drain

  • irrigate the portals


Deep closure

  • use 3-0 biosyn for closure


Superficial closure

  • use 4-0 biosyn for skin


Dressing and immediate immobilization

  • place sling
Postoperative Patient Care
Private Note

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