Preoperative Patient Care A Outpatient Evaluation and Management 1 Obtains focused history and performs physical examination provocative tests differential diagnosis and physical exam tests 2 Orders basic imaging studies radiographs AP true AP with active shoulder abduction Axillary lateral Scapular Y view 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 active assisted ROM exercises external rotation 0 to 30 degrees forward elevation (0 to 90) for 6 weeks weeks 6 to 12 weeks include active assisted and active range of motion with the goal of establishing full range of motion start strengthening exercises after full ROM is achieved diagnose and management of early complications 3 month postoperative visit sports specific exercises at 16 to 20 weeks final release to full activity 20 to 24 weeks B Advanced Evaluation and Management 1 Interpret basic imaging studies radiographs MRI labral tears arthritis 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 recurrent instability loss of external rotation from overtightening rupture of the repair can occur with aggressive early activities injury to the axillary nerve 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 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 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 Glenoid Preparation 1 Maneuver the arthroscope move the arthroscope to the anterosuperior portal 2 Place cannula place another 8.25 mm cannula in the posterior portal 3 Release the tissues release the labral and ligamentous complex off of the face of the glenoid maintain the tissue as one unit use elevators to release to at least the 6 oclock position release is known to be adequate when the subscapularis is visible 4 Prepare the glenoid neck prepare the glenoid neck using either a burr or a shaver to decorticate down to bleeding bone A meniscal rasp can be a useful adjunct the bone preparation must be as inferior as the soft tissue release on the glenoid it is important to begin the repair at the low 6 oclock position in the capsule J Anchor Placement 1 Place the arthroscope in the posterior portal for anchor placement 2 Place the suture passing instrument place the suture passing instrument through the anteriorinferior cannula to capture tissue 3 Maneuver the arthroscope place the arthroscope in anterosuperior portal 4 Place the shuttling instrument place the shuttling instrument in the anteroinferior portal 5 Pierce the capsule pierce the capsule 5 to 10 mm lateral to the labrum exit the capsule and pierce the capsule again to re-enter at the lateral base of the labral complex and emerge at the articular margin 6 Place the suture A monofilament suture is inserted to be used as a shuttle suture the shuttling suture or device will eventually be used to shuttle the nonabsorbable suture housed in the anchor all shuttling should be done from the articular side of the labrum out to the soft tissue side and through a cannula place the initial suture inferiorly on the glenoid close to the 6 o`clock position suture anchors should be placed on to the articular face of the glenoid to recreate the bumper effect of the normal labrum it is critical to place anchors 5 to 10 mm cephalad to the shuttle suture to accomplish the superior shift portion of the procedure if appropriate access for anchor placement cannot be gained from the anteroinferior use percutaneous transsubscapular entry in this case a stab incision is made just inferior to the anteroinferior portal using needle localization confirm the appropriate access K Capsular Plication and Posterior Anchors 1 Perform capsular plication and anchoring repeat the process of capsular plication and anchoring in a superior direction to restore labral anatomy and retensioning the inferior glenohumeral ligament most times 4 anchors are used in the final construct it may be necessary to return the arthroscope to the posterior portal for placement of the most cephalad anchor this is the 2 oclock position for the right shoulder 2 Perform enhancing techniques when indicated place stitches place the initial stitch in the inferior capsule bring the stitch out of the anterosuperior portal apply traction traction allows more inferior grasp of tissue in the early stages of a repair place posterior anchors place the posterior anchors when a bankhart lesion extends posteriorly past the 6 oclock position L Plication Stitches and Closure of the Rotator Interval 1 Place plications stitches if the posterior labrum is intact but there is posterior laxity plication stitches function to balance the anterior and posterior tension on the inferior glenoid ligament grasp the capsule and connect it to the labrum using the pinch-tuck technique 2 Close the rotator interval indicated if there is greater than 1+sulcus sign, laxity with a posterior component or a collision athlete pass the stitch pass a stitch through a suture placed in the anterosuperior cannula through the superior border of the subscapularis or the MGHL pierce the superoglenohumeral and coracohumeral complex with a tissue penetrator to grasp the suture tie knots tie and cut the knot with a guillotine knot cutter N Wound Closure 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 controlled immobilization in an abduction orthosis codman exercises and pendulum exercises immediately with assistance R Complex Patient Care 1 Modifies and adjusts post operative rehabilitation plan as needed post-operative stiffness 2 Order and interpret advanced imaging studies MRI 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 differential diagnosis and physical exam tests 2 Orders basic imaging studies radiographs AP true AP with active shoulder abduction Axillary lateral Scapular Y view 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 active assisted ROM exercises external rotation 0 to 30 degrees forward elevation (0 to 90) for 6 weeks weeks 6 to 12 weeks include active assisted and active range of motion with the goal of establishing full range of motion start strengthening exercises after full ROM is achieved diagnose and management of early complications 3 month postoperative visit sports specific exercises at 16 to 20 weeks final release to full activity 20 to 24 weeks B Advanced Evaluation and Management 1 Interpret basic imaging studies radiographs MRI labral tears arthritis 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 recurrent instability loss of external rotation from overtightening rupture of the repair can occur with aggressive early activities injury to the axillary nerve
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 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 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 Glenoid Preparation 1 Maneuver the arthroscope move the arthroscope to the anterosuperior portal 2 Place cannula place another 8.25 mm cannula in the posterior portal 3 Release the tissues release the labral and ligamentous complex off of the face of the glenoid maintain the tissue as one unit use elevators to release to at least the 6 oclock position release is known to be adequate when the subscapularis is visible 4 Prepare the glenoid neck prepare the glenoid neck using either a burr or a shaver to decorticate down to bleeding bone A meniscal rasp can be a useful adjunct the bone preparation must be as inferior as the soft tissue release on the glenoid it is important to begin the repair at the low 6 oclock position in the capsule J Anchor Placement 1 Place the arthroscope in the posterior portal for anchor placement 2 Place the suture passing instrument place the suture passing instrument through the anteriorinferior cannula to capture tissue 3 Maneuver the arthroscope place the arthroscope in anterosuperior portal 4 Place the shuttling instrument place the shuttling instrument in the anteroinferior portal 5 Pierce the capsule pierce the capsule 5 to 10 mm lateral to the labrum exit the capsule and pierce the capsule again to re-enter at the lateral base of the labral complex and emerge at the articular margin 6 Place the suture A monofilament suture is inserted to be used as a shuttle suture the shuttling suture or device will eventually be used to shuttle the nonabsorbable suture housed in the anchor all shuttling should be done from the articular side of the labrum out to the soft tissue side and through a cannula place the initial suture inferiorly on the glenoid close to the 6 o`clock position suture anchors should be placed on to the articular face of the glenoid to recreate the bumper effect of the normal labrum it is critical to place anchors 5 to 10 mm cephalad to the shuttle suture to accomplish the superior shift portion of the procedure if appropriate access for anchor placement cannot be gained from the anteroinferior use percutaneous transsubscapular entry in this case a stab incision is made just inferior to the anteroinferior portal using needle localization confirm the appropriate access K Capsular Plication and Posterior Anchors 1 Perform capsular plication and anchoring repeat the process of capsular plication and anchoring in a superior direction to restore labral anatomy and retensioning the inferior glenohumeral ligament most times 4 anchors are used in the final construct it may be necessary to return the arthroscope to the posterior portal for placement of the most cephalad anchor this is the 2 oclock position for the right shoulder 2 Perform enhancing techniques when indicated place stitches place the initial stitch in the inferior capsule bring the stitch out of the anterosuperior portal apply traction traction allows more inferior grasp of tissue in the early stages of a repair place posterior anchors place the posterior anchors when a bankhart lesion extends posteriorly past the 6 oclock position L Plication Stitches and Closure of the Rotator Interval 1 Place plications stitches if the posterior labrum is intact but there is posterior laxity plication stitches function to balance the anterior and posterior tension on the inferior glenoid ligament grasp the capsule and connect it to the labrum using the pinch-tuck technique 2 Close the rotator interval indicated if there is greater than 1+sulcus sign, laxity with a posterior component or a collision athlete pass the stitch pass a stitch through a suture placed in the anterosuperior cannula through the superior border of the subscapularis or the MGHL pierce the superoglenohumeral and coracohumeral complex with a tissue penetrator to grasp the suture tie knots tie and cut the knot with a guillotine knot cutter N Wound Closure 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 controlled immobilization in an abduction orthosis codman exercises and pendulum exercises immediately with assistance R Complex Patient Care 1 Modifies and adjusts post operative rehabilitation plan as needed post-operative stiffness 2 Order and interpret advanced imaging studies MRI 3 Treats intra-operative and post operative complications irrigation and debridement for infection proper infection treatment infectious disease consultation
All Videos (1) Podcasts (0) Login to View Community Videos Login to View Community Videos 2016 Chicago Sports Medicine Symposium Live Surgery Broadcast - 7AM - Saturday, August 6, 2016 - Brian Cole, MD, MBA & Shane Nho, MD, MS (CSMS #94, 2016) Brian Cole Approaches - Bankart Repair with capsular plication- Arthroscopic B 10/25/2016 336 views 3.7 (3)