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 and interprets 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 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 5 Provide basic post op management (treat as if a large/massive cuff repair) postop: 2 week postoperative visit wound check rehabilitation remain in ultra sling for 6 weeks start passive ROM at 4 weeks at 6 weeks remove sling and start progressive active ROM exercises diagnose and management of early complications<br /> B Advanced Evaluation and 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 radiographs identify is glenohumeral osteoarthritis is moderate to severe 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 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 Evaluate radiographs for rotator cuff arthropathy and glenohumeral arthritis perform a Reverse TSA if XRay shows sign of moderate or severe genohumeral osteoarthritis 2 Evaluate shoulder MRI for massive cuff tear and fatty infiltration MRI shows rotator cuff tear with Goutallier Grade III or IV fatty infiltration. 3 Perform exam under anesthesia 4 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 standard OR table for lateral decubitus position 3 Patient Positioning (lateral) place patient in the lateral decubitus position pad any prominences of the extremities position the head and neck in neutral alignment support the head with a foam head cradle protect the eyes with tape place an axillary role under the upper chest to protect the lower shoulder and axilla ensure the entire scapula is free from the edge of the table 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 G Scope Insertion 1 Outline landmarks Outline the acromion, distal clavicle, coracoid process and biceps tendon 2 Place posterior portal Mark portal 2 to 3 cm distal and 1 to 2 cm medial to the posterior lateral tip of the acromion Make 4mm skin incision Place scope cannula with a blunt trocar into the incision and enter the joint. 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 H Diagnostic Arthroscopy 1 Peform 15 point diagnostic arthroscopy 1. Biceps tendon and biceps anchor 2. Posterior labrum and posterior capsular pouch 3. Inferior capsular pouch and inferior aspect of the humeral head (? osteophyte) 4. Glenoid articular cartilage 5. Articular surface of the rotator cuff and rotator cuff crescent 6. Posterior rotator cuff attachment and bare area of the humeral head (?Hill-Sachs lesion) 7. Humeral head weight bearing articular cartilage surface 8. Anterior superior labrum and rotator interval 9. Subscapularis tendon and Middle Gleno-Humeral ligament 10. Anterior-Inferior labrum and ligaments 2 Insert the scope in the anterior portal and perform the final 5 points of the 15-point exam 11. Posterior labrum and posterior inferior capsule 12. Posterior superior capsule and posterior rotator cuff tendon 13. Anterior inferior labrum and ligaments 14. Subscapularis tendon and subscapularis recess medial to the glenoid 15. Anterior surface of the humeral head and subscapularis attachment Debride synovitis and cartilage lesions I Biceps Management and Subacromial Bursectomy 1 Perform biceps tenotomy vs tenodesis Tenotomy: cut biceps tendon at anchor with 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 scissors. leave spinal needle to hold tendon 2 Perform subacromial bursectomy Move trocar into subacromial space move the arthroscope to the subacromial space slide the trocar under the acromiom over the posterior rotator cuff sweep under the acromiom through the lateral gutter to break up adhesions Identify the CC ligament found on the anterior aspect of the subacromial space Perform a Bursectomy use the shaver to perform a lateral and anterior bursectomy through anterior portal 3 Perform biceps tenodesis Move camera to Posterior lateral portal use Spinal needle to make a posterior lateral portal just off the acromion. this allows for visualization down into the bicipital groove in the humerus. Make stab incision use switching sticks to place camera into posterior lateral portal, place canula into the original posterior portal. Localize biceps tendon in groove use Pre-operative biceps marking as guide Place passport canula centered over tendon in grove Release the roof of the bicipital grove 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 J Rotator Cuff Evaluation, Acromioplasty and Distal Clavicle Resection 1 Evaluate rotator cuff tear Insert an atraumatic grasper through the lateral subacromial portal and asses rotator cuff tear lateral excursion. If there is possibility of repair, attempt. If not, proceed with superior capsular reconstruction. If there is a subscapularis tear it must be repaired to ensure humeral head stabilization with the SCR. 2 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 with burr carry the resection medially to the AC joint make the resection level by sweeping the burr from anterior to posterior 3 Distal Clavicle Excision (if performed) Expose distal clavice use RF from lateral portal to clean out and expose the distal clavicle place RF in anterior portal so its parallel with AC joint and continue to expose Resect with burr through anterior portal use 5.0mm burr to resect distal clavicle from anterior to posterior resect only 8m-1CM of distal clavicle if more is done will release the CC ligaments and cause instability be careful to not release the superior capsular of AC joint K Superior Capsular Reconstruction (SCR) and Graft Preparation 1 Begin superior capsular reconstruction Prepare greater tuberosity use shaver or burr to decorticate greater tuberosity 2 Prepare Glenoid use RF and shaver to remove superior labrum expose superior glenoid use shaver or burr to decorticate superior glenoid 3 Place Lateral Portal Passport place 12mm passport cut 25% of the inner ring off so that future anchor placement is easier spin the cut section superiorly 4 Place glenoid anchors Create a superior portal (Neviaser) portal medial to acromial, posterior to clavicle, anterior to supraspinatus spine use spinal needle to find trajectory that allows for glenoid anchor placement Glenoid anchor placement place drill guild through superior portal. drill and keep guild in place for anchor placement. place 2-3 knotless 2.9mm suture tack anchors. (depending on size of glenoid) anterior to posterior. place hemostat on limbs from each anchor occasionally may need to make another portal just posterior to the first to get trajectory for 3 anchors. 5 Place greater tuberosity anchors use spinal needle just lateral off lateral border of acromion. small stab incision to allow for punch and anchor passage. Place Anchors place first 4.75mm fibertape loaded anchor on the anterior greater tuberosity use suture grasper to take suture out anterior canula place second 4.75mm fibertape loaded anchor on the posterior tuberosity use grasper to take suture out of posterior cannula. 6 Measure Graft Measure Anterior and Lateral bring the suture from the anterior humeral anchor out the speed bridge and apply the intra-articular suture measurement device meausre the distance between the 2 humeral anchors and write down the number. (Lateral) measure the distance between the anterior humeral anchor and the most anterior glenoid anchor and write down the number (Anterior) Measure Posterior and Medial bring the suture from the posterior glenoid anchor out the speed bridge and apply the intra-articular measurement device Measure the distance between the most posterior and anterior glenoid anchors write down the number. (Medial) Measure the distance between the posterior humeral anchor and the most posterior glenoid anchor and write down the number (Posterior) 7 Prepare graft Draw rectangular diagram on back table with distances of Anterior, Posterior, Medial, and Lateral. Use graft of 3.0mm thickness, human dermal allograft. Add 1cm to each side of the rectangular dimensions created by the anchors. Draw the dimension on the graft and cut out appropriate sized graft have assistant hold the edges of allograft (that will not be used) with hemostat and cut out correct sized graft with very sharp scissors. note the "smooth" and "rough" sides of the graft. the smooth will be superior in the shoulder, rough will be inferior and allow for graft incorporation on glenoid and humerus. Mark graft so medial, lateral, posterior and anterior is known holes can be punched on the location of suture passing. L Graft Suture Passing 1 Pass sutures through graft on the outside of shoulder 2 Pass sutures from glenoid on medial aspect of graft Grab and bring the anterior sutures from the glenoid out the passport. Through previously punched holes or use of arthroscopic suture passer, pass the suture from the underside of the graft up, and then down on the anterior medial aspect of the graft (a horizontal mattress stitch). Repeat for the second/third gleoind anchor suture. Be careful of spacing and suture mamagement so not tangled. you now have the pulley sutures to help facilitate pulling the graft into the shoulder with the lateral row sutures in the anterior and posterior canulas, lessens the chance of tangles. 3 Pass sutures from humerus throught lateral aspect of graft Grab and bring out the anterior sutures of the lateral row out the passport. Through previously punched holes or use of arthroscopic suture passer, pass the suture from the underside of the graft up on the anterior lateral aspect of the graft. Grab and bring out the posterior sutures of the lateral row out the passport and repeat passing through graft posteriorly. 4 Deliver SCR Graft Into shoulder Pull the medial pulley sutures coming out of superior portal. Pull the graft right up to the passport Isolate the lateral sutures so they are not tangled Use a kingfisher to grab the medial aspect of the graft. While carefully pulling on medial glenoid pulley sutures and pushing with kingfisher, deliver graft into the shoulder through the passport. 5 Fixation of graft on glenoid With the use of knotless 2.9mm suture anchors, the pulley sutures will pull down and lock the graft medially on the glenoid. 6 Fixation of graft on humerus Cut the tape sutures so they are now 4 separate strands (previously combined when passed). Grab one from anterior the other one from the posterior anchor for lateral fixation. Load the suture tape into the the swivel lock anchor Punch and place with some tension into the posterior lateral aspect. Repeat with the remaining 2 sutures anteriorly on the humerus. 7 Posterior side to side stitches Load free 2-0 fiberwire suture into the arthroscopic suture passer and pass and tie a simple stitch from the infraspinatus to the medial posterior graft. Repeat working medial to lateral (usually 2-3 stitches) N Wound Closure 1 Closing the portals and dressing the incisions withdraw the instruments 2 Close the incisions with a single subcuticular stitch use 4-0 monocryl suture 3 Apply steristrips 4 Place dressings place Prowicks sponges that are primed with liquid betadine solution over the incisions place and wrap Prowick dressings over the incision cut the arm portion of the wrap to relieve pressure around the axilla and upper humerus. 5 Place sling support the patients arm in an Ultrasling with abduction pillow.
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 do not remove sling and no motion for 6 weeks R Complex Patient Care 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