A Basic Preoperative or Nonoperative Evaluation & Management 1 Obtains focused history and performs physical examination Provocative tests Neer/Hawkins O'Briens Speed/Yergaons Positive throwing test Tenderness over biceps tendon lag signs pseudoparalysis lift-off belly press scapular dyskinesia Differential diagnosis and physical exam tests 2 Orders and interprets basic imaging studies Radiographs AP Axillary lateral Scapular Y view 3 Understands indications and prescribes non-operative treatment Physical therapy stretching, rotator cuff and scapular stabilizer strengthening exercises Anti-inflammatory medication Cortisone injections in the subacromial space 4 Understands basic indications and required workup to proceed with operative treatment Documents failure of nonoperative management Describes accepted indications and contraindications for surgical intervention B Advanced Preoperative or Nonoperative Evaluation & Management 1 Performs advanced history and physical exam to makes diagnosis among differential diagnosis. Can perform history to eliminate complete differential diagnosis. can identify history of scapular winging, cervical radiculopathy, and other conditions that may present with shoulder pain. 2 Interpret advanced imaging studies MRI muscle atrophy labral tears arthritis subscapularis tears evaluates both the tendon and muscle quality 3 Able to perform diagnostic and therapeutic injections of the shoulder (subacromial, intra-articular) C Preoperative History & Physical and Medical Clearance P 1 Obtain history and perform physical exam History age gender smoker trauma night pain Past Medical History identify medical co-morbidities that might impact surgical treatment Physical exam check range of motion weakness of the extremity inspect for atrophy Labs Pearls H&P must be performed 30 days prior to surgery or else it is considered out of date. 2 Confirm appropriate medical clearance obtained 3 Perform operative consent Describe complications of surgery including infection stiffness RSD retear
E Preoperative Plan 1 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 1 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 1 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 1 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 1 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 1 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 1 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 1 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 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.
O Postoperative Inpatient Management & Discharge 1 Postoperative Check ensure patient has appropriate pain control check wound neurovascular check of operated extremity 2 Discharge Pain Medications document preoperative opiate use write postoperative triplicate for narcotics and document in EMR if given to patient 3 Prescribe discharge early immobilization place in sling with abduction pillow for small and medium cuff repairs use of ultra sling for 4 weeks ensure patient has clear understanding of sling percautions including sleeping and showering 4 Prescribe early rehabilitation at discharge start only pendulum exercises until 2 weeks postoperative check 5 Schedule 2 week followup at discharge R Postoperative Management of Complex Patient with Surgical Complications 1 Is able to perform a detailed history and physical exam to diagnosis cause of failure or complication. Modify for massive cuff repairs Post-operative stiffness 2 Order and interpret advanced imaging studies in order to confirm cause of failure or complication. MRI evaluates both the tendon and muscle quality muscle atrophy labral tears arthritis subscapularis tears full thickness tears show increased signal intensity at the tendon insertion on T-2 weighted images 3 Able to perform invasive studies to confirm the diagnosis. This includes aspirating the joint to rule out sub-clinical infection 4 Treats intra-operative and post operative complications Irrigation and debridement for infection Proper infection treatment Infectious disease consultation