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
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 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
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