Rotator Cuff Tears Pathway Updated: 2/13/2020
CPT Codes: 29827, Arthroscopy, shoulder, surgical; with rotator cuff repair 29824, Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (mumford procedure) 29828, Arthroscopy, shoulder, surgical; biceps tenodesis 29826 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure)

Medium Full-Thickness Rotator Cuff Repair, SAD, DCR, and Biceps Tenodesis - Dr. Matthew Pifer

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TECHNIQUE STEPS
Preoperative Patient Care
Operative Techniques
E

Preoperative Plan

1

Evaluate radiographs and MRI

  • Radiographs - osseous anatomy
  • Acromion type
  • AC joint
  • Glenohumeral joint
  • MRI - soft tissue anatomy
  • Labrum
  • Biceps
  • Rotator cuff

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

P

1

Make sure tower is 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

  • Standard OR table for lateral decubitus position
  • Arm boom for lateral position.

3

Exam under anesthesia

Pearls
  • Note forward flexion, abduction, and internal and external rotation with arm at side and at 45 degrees abduction

4

Patient Positioning
(lateral)

  • Place patient in the lateral decubitus position
  • Pad any prominences of the extremities
  • Position the head and neck in neutral alignment
  • Protect the eyes
  • Place an axillary role under the upper chest to protect the lower shoulder and axilla
  • Support the arm with the Meisel mitten in the arthroscopy position with 10 pounds of traction
  • Prep and drape the arm in the usual fashion for shoulder arthroscopy
Pearls
  • If patient is tilted with back to floor around 20 degrees makes for easier access for biceps tenodesis if planned. Otherwise shoulder perpendicular to floor is standard.
G

Scope Insertion

P

1

Outline landmarks

  • Outline the acromion, distal clavicle, coracoid process, and biceps tendon
Pearls
  • Marking the biceps path helps with localization of the tendon if a arthroscopic tenodesis is performed.

2

Place posterior portal

  • Mark portal 2 to 3cm distal and 1 to 2cm medial to the posterior lateral tip of the acromion
  • Make stab skin incision
  • Place scope cannula with a blunt trocar into the incision and enter the joint.
  • aim for the base of the coracoid
  • Place the 30° arthroscope.
Pearls
  • Can pull extra traction on arm to open joint further for easier scope insertion.

3

Place anterior portal

  • Halfway between acromioclavicular joint and the lateral aspect of the coracoid
  • Use spinal needle to find trajectory though center of rotator interval between supraspinatus and subscapularis
  • Make stab skin incision
  • Place anterior cannula.
H

Diagnostic Arthroscopy and Intra-Articular Biceps Management

P

1

Perform diagnostic arthroscopy

  • Subscapularis tendon
  • Anterior superior labrum and rotator interval
  • Biceps tendon and biceps anchor
  • Superior rotator cuff tendon, attachment, and crescent
  • Posterior labrum and posterior capsular pouch
  • Posterior rotator cuff attachment and bare area of the humeral head
  • Posterior superior capsule and posterior rotator cuff tendon
  • Inferior capsular pouch and inferior aspect of the humeral head
  • Glenoid articular cartilage
  • Humeral head weight bearing articular cartilage surface

2

Debride pathology as needed

3

Perform biceps tenotomy vs tenodesis if warranted

  • Tenotomy: cut biceps tendon at anchor with curved sissors
  • Tenodesis:
  • pierce biceps tendon with spinal needle coming into the joint from the anterior lateral acromial border, though the rotator cuff interval, and through the biceps tendon
  • after pierced and held, cut tendon at anchor with curved scissors
  • leave spinal needle to hold tendon until completion of tenodesis in the sub deltoid space
Pearls
  • Discuss risk and benefits of biceps tenotomy vs tenodesis pre-operatively and know which one will be performed if warranted.
I

Subacromial Bursectomy and Biceps Tenodesis

P

1

Perform subacromial bursectomy

  • Move trocar into subacromial space
  • move the arthroscope to the subacromial space
  • slide the trocar under the acromion over the posterior rotator cuff
  • sweep under the acromion through the lateral gutter to break up adhesions
  • Identify the CC ligament
  • found on the anterior aspect of the subacromial space
  • Redirect and place anterior cannula into the subacromial space
  • Perform a Bursectomy
  • use the shaver to perform a lateral and anterior bursectomy through anterior portal
Pearls
  • Visualize the shaver tip when starting the bursectomy.

2

Perform biceps tenodesis

  • Move camera to a high posterior lateral portal and place posterior cannula
  • allows for visualization down into the bicipital groove and distally on the humerus.
  • use spinal needle to find trajectory above the rotator cuff footprint on the greater tuberosity
  • make stab incision
  • place switching stick
  • remove camera from sheath in posterior portal and place another switching stick in its place
  • place camera sheath over switching stick in high posterior lateral portal
  • remove switching stick and place camera.
  • place a cannula over posterior portal switching stick and remove stick.
  • Use shaver in anterior portal to perform sub-deltoid bursectomy
  • Localize biceps tendon in groove
  • use needle holding biceps and pre-operative biceps marking as guide
  • insert spinal needle half way down axilla on the biceps marking guide and palpate biceps tendon
  • make a 4mm stab incision
  • use shaver to debride sub-deltoid bursa and measure for depth size for passport cannula
  • Place passport cannula centered over tendon in groove
  • Release the roof of the bicipital groove
  • use RF to feel the tendon and start by releasing lateral
  • careful to not cut tendon itself
  • Size the tendon
  • use tendon sizer
  • most common size is 7mm & 8mm
  • Isolate tendon medially
  • use tendon sizer to push tendon medial and place a spinal needle into it to hold position
  • Drill potting hole
  • use a piloted reamer that is 5mm larger than the selected implant
  • Remove spinal needle holding tendon medially
  • tendon will return to position and be above the hole
  • implant biceps specific forked screw and tendon
  • push forked screw implant into passport and down onto tendon above the hole
  • place tension with forked implant
  • implant until screw is flush with cortex
  • will have tension via proximal spinal needle holding it
  • remove the proximal spinal needle
  • screw down implant and fix tendon
  • Remove the remaining stump of the proximal tendon
  • use curved scissors to cut the proximal stump at near the tenodesis point
  • debride the remaining stump down with RF
J

Rotator Cuff Evaluation, Tendon Debridement and Footprint Preparation

P

1

Create a lateral portal

  • Place lateral off acromion slightly anterior
  • Use spinal needle to find trajectory to mid tear of cuff

2

Evaluate rotator cuff tear

  • Assess rotator cuff tear for lateral excursion
  • Assess tear dimensions, shape, and ability to repair back to footprint with the least amount of tension

3

Debride Cuff Tendon

  • Debride the tear edge down with a shaver until there is robust edge

4

Prepare footprint

  • Use RF and shaver to remove soft tissue from the greater tuberosity
  • Use shaver or burr to decorticate and allow for a good bleeding bone footprint for repair
Pearls
  • Typically the passport cannula for the lateral portal is the same size as the one used for the biceps tenodesis.

5

Place passport cannula

  • Place appropriate sized passport cannula
  • cut 1/4 of the inner ring off cannula before insertion and spin cannula until the open section is superior
  • this allows for easier future passage of anchors between the acromion and passport
K

Rotator Cuff Repair - Knotless Double Row Transosseous Equivalant

P
P

1

Create small anchor placement portal

  • Just lateral off acromion superior to passport cannula
  • Use spinal needle to find appropriate trajectory to greater tuberosity
  • should go through previously cut portion of inner ring of passport
  • Make a stab incision
Pearls
  • Trajectory is through previously cut portion of inner ring of passport

2

Place anchor

  • Place anterior anchor first
  • Place anchor hole punch through anchor portal and direct to anterior aspect of footprint
  • Prepare a bone socket with punch and note the relative density of bone
  • if bone is dense or hard will have to tap before screwing in anchor
  • tap bone socket if needed
  • Insert the 4.75 mm vented biocomposite anchor preloaded with fibertape loop
  • this is the medial row anchor of the "double row" construct
Pitfalls
  • For hard bone, make sure you tap first. Hard bone can break bio-composite anchors.

3

Pass suture through cuff

  • Take looped suture out of lateral passport portal with the use of a suture grasper
  • if the cuff tear is larger, then the looped suture can be cut before passing into 2 separate strands for passing and creating a larger repair area
  • Load suture into arthroscopic suture passer and pass the suture through the cuff on the anterior aspect of the tear
  • Retrieve passed suture out of anterior portal
Pearls
  • If the tear is bilaminar make sure the suture is passed medially enough to pass through the entire tendon remnants.

4

Place posterior anchor

  • Repeat anchor placement and suture passing steps for the posterior anchor
  • place anchor on the posterior aspect of the footprint repair site

5

Create lateral row anchors

  • Posterior anchor first
  • Retrieve one fibertape from each medial anchor (one anterior and one posterior) out of the lateral passport portal
  • Load fibertape into the 4.75mm biocomposite anchor
  • Using a punch, create a posterior bone socket 5-10mm lateral to the edge of the tuberosity

6

Reduce cuff tissue to the footprint

  • Bring the eyelet of the lateral row implant to the edge of the bone socket
  • remove slack from the limb of each fibertape limb individually
  • Apply tension to the sutures so that the cuff tissue is reduced and compressed against the bone.
  • Advance and secure lateral anchor

7

Cut tails

  • Cut the suture tails with an arthroscopic suture cutter.
  • Posterior lateral row is now placed

8

Repeat steps for lateral row creation and cuff placment on footprint for anterior anchor.

Pearls
  • The core suture in the lateral row anchors can be used to tie down any dog ears left from the repair.

9

Remove all cannulas and reposition the camera back into the posterior portal in the subacromial space.

L

Subacromial Decompression and Distal Clavicle Resection

P
P

1

Perform subacromial decompression

  • Place RF through the lateral portal and clean off all periosteum on the underside of the acromion
  • Perform acromioplasty
  • partially resect the CC ligament with the ablation wand to expose the entire acromion
  • start the acromioplasty at the anterior lateral corner and remove 5 to 8mm of bone with burr
  • amount resected should be dependent on acromial grade noted in preoperative XRays
  • carry the resection medially to the AC joint
  • make the resection level by sweeping the burr from anterior to posterior

2

Perform distal clavicle resection

  • Expose distal clavicle
  • use RF from lateral portal to clean out and expose the distal clavicle
  • place RF in anterior portal so it's parallel with AC joint and continue to expose
  • Resect with burr through anterior portal
  • use 5.0 mm burr to resect distal clavicle from anterior to posterior
  • resect only 8mm-1cm of distal clavicle
  • if more is done will release the CC ligaments and cause instability
  • be careful to not release the superior capsule of AC joint
Pearls
  • The entire distal clavicle should be visualized to the posterior aspect of the clavicle to ensure complete resection.
Pitfalls
  • If more than 1cm of distal clavicle is resected then potential for release of the CC ligaments and cause clavicle instability
N

Wound Closure

1

Close portals

  • Withdraw the instruments
  • Close the incisions with a single subcuticular stitch
  • use 4-0 monocryl suture

2

Apply steristrips

3

Place dressings

  • Place xeroform over the incisions
  • Place 4x4s and 2-3 ABDs
  • For final layer place waterproof foam tape with no tension

4

Place sling

  • Support the patient's arm in sling with abduction pillow.
Postoperative Patient Care
 

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