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Bankart Repair with capsular plication- Arthroscopic

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
 

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