Updated: 12/5/2016
CPT Codes: 29827 Arthroscopy, shoulder, surgical; with rotator cuff repair

Massive Rotator Cuff Repair with Augmentation - Arthroscopic

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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

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

  • lateral decubitus position
  • pad any prominences of the extremities
  • position the head and neck in neutral alignment
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 burr from a medial to lateral direction
J

Capsule Incison, Tendon Preparation, and Tendon Mobilization

1

Insert grasper

  • insert an atraumatic grasper through the lateral subacromial portal

2

Assess the cuff mobility from the articular side

  • if the supraspinatus tendon mobility is poor release the superior capsule

3

Place instrument into the lateral portal

  • insert an arthroscopic elevator or electrosurgical cutting device through the lateral subacromial portal

4

Incise the capsule

  • cut the through the capsule between the cuff tendon and glenoid rim from the rotator interval anteriorly to the scapular spine posteriorly
  • if a crescent shaped tear does not reduce to bone or a longitudinal tear does not close from side to side, perform an arthroscopic interval slide
  • place the camera in the posterior intraarticular portal
  • insert a narrow basket punch into the subacromial portal through the tear in the cuff and into the joint
  • divide the interval between the anterior border of the supraspinatus and the superior capsule from lateral to medial
  • this also releases the tendon from the contracted coracohumeral ligament on the bursal side
  • with the biceps tendon intact make the release just caudad to the tendon
  • if the biceps is not intact start the release approximately at the anterosuperior pole of the glenoid

5

Make portal if needed

  • make a small percutaneous portal adjacent to the lateral subacromial portal
  • place a grasper and pull on the tendon laterally
K

Anchor Placement, Suture Passage, Definitive Knots

1

Footprint Preparation

  • use shaver to remove soft tissue from the greater tuberosity
  • make sure to expose the cortical bone

2

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

3

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
  • 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
L

Allograft Reinforcement of Tendon Repair (Optional)

1

Measure the dimensions of the graft

  • measure the size of the graft from anterior to posterior and medial to lateral dimensions
  • use a knotted suture measuring device

2

Prepare the graft

  • preoperatively prepare a size 0 braided suture with 6 knots
  • these should be spaced 1 cm apart
  • hold the measuring suture with a grasper on one end
  • pass the other end into a knot pusher so that the suture with its knots can easily slide back and forth through the eyelet of the knot pusher
  • most grafts require six suture points of fixation
  • space these points evenly like the odd numbers on a face of clock
  • use two suture for lateral fixation into the greater tuberosity
  • these are simple #2 braided permanent suture that are passed through the tissue with there ends tied together to prevent pullout from the graft
  • place short-tailed interference knot (STIK) sutures evenly spaced for posterior, medial, and anterior tissue fixation
  • make a midline ink mark on the lateral aspect of the graft as a reference point

3

Pass the sutures through the tissue

4

Remove the graft from the back table

  • bring the graft adjacent to the anterolateral cannula
  • clip a wet towel around the upper arm
  • place the graft on the towel

5

Orient the graft anatomically

6

Suture the graft

  • start sequential suturing posteriorly and progress medially and anteriorly
  • have an assistant select and hold the most posterior STIK suture
  • clip the grafts two lateral sutures to the towel with a hemostat and stabilize it
  • use curved suture hooks sequentially shuttle down to the four STIK sutures down the anterolateral cannula through the rotator cuff

7

Pass the suture hook

  • pass a suture hook starting posteriorly through and through the rotator cuff tissue
  • pass a shuttling suture out of the anterolateral cannula with a grasper
  • shuttle the free end of the corresponding posterior STIK suture through the cuff tendon and back out of the posterior cannula
  • repeat this shuttling technique progressing medially then anteriorly

8

Bring the graft into the shoulder

  • insert the graft through the anterolateral cannula
  • pull the slack out of all suture
  • this docks the graft at the aperture of the anterolateral cannula
  • roll the graft onto itself to facilitate passage through the cannula
  • use a push pull technique
  • as the graft is pushed down the cannula using a small thin grasper
  • pull the STIK ends of the suture from the posterior and anterior cannulas
  • once the graft is in the shoulder sequentially tighten ech suture end to unfold the graft and cover the repair site

9

Secure the graft

  • tie each STIK knot sequentially
  • use 2 push in suture anchors to stabilize the lateral edge of the graft over the lateral tuberosity
  • abduct the arm to the midposition of 45 degrees to access the lateral tuberosity
  • take the two limbs for the posterolateral suture into the posterior cannula
  • create a pilot hole in the anterolateral greater tuberosity
  • load the 2 anterolateral suture limbs into the push in anchor outside of the cannula
  • place the anchor through this cannula into bone
  • bring the posterior lateral suture limbs back into the anterolateral cannula
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
 

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