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 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 postop: 2 week postoperative visit wound check postop: 4 weeks remove sling start PT start non-weightbearing active range of motion at the elbow postop: 6 weeks start progressive weightbearing as tolerated at elbow 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 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
D Simulation 1 Cadaveric demonstration of surgical approach and therapeutic skill 2 Sawbones demonstration of proper instrumentation E Preoperative Plan 1 Evaluate radiographs and MRI Biceps tendon or labral pathology (SLAP tear) that indicates a tenodesis procedure. 2 Perform exam under anesthesia 3 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 (RF) 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 Perform 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. Biceps Tendon 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 3 Debride tissues Debride synovitis and cartilage lesions I Intra-Articular Biceps Management 1 Start tenodesis in glenohumeral compartment 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 in place to the end of the procedure to hold and anchor the tendon debride tendon stump and labrum with shaver J Subacromial Space Management 1 Perform subacromial bursectomy Move trocar into SAS slide the trocar under the acromiom over the posterior rotator cuff sweep under the acromiom through the lateral gutter to break up adhesions 2 Identify the CA ligament found on the anterior aspect of the subacromial space 3 Reposition the anterior cannula Push the trochar through the anterior portal, slide anterior cannula over, insert camera, now camera and ant trochar in subacromial space. 4 Perform a Bursectomy Use the shaver to perform a lateral and anterior bursectomy through anterior portal K Tendon Preparation 1 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 2 Make stab incision use switching sticks to place camera into posterior lateral portal, place canula into the original posterior portal 3 Localize biceps tendon in groove and create a portal over tendon use pre-operative biceps marking as guide make stab incision approximatly 1/2 down to axilla 4 Insert shaver for further bursectomy 5 Measure for passport cannula Measure and place passport cannula centered over tendon in groove 6 Release the roof of the bicipital grove Use shaver or RF to feel the tendon, and start by releasing lateral careful to not cut tendon itself 7 Size the tendon Use tendon sizer most common size is 7mm & 8mm 8 Isolate tendon medially Use tendon sizer to push tendon medial and place a spinal needle into it to hold position L Implant Fixation 1 Drill Potting hole Use a piloted reamer that is 5mm larger than the selected implant 2 Remove spinal needle holding tendon medially Tendon will return to position above the hole 3 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 4 Debride the remaining tendon Use curved scissors to cut remaining tendon and remove with grasper through passport Use shaver or RF to debride down remaining stump 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 regular sling.
O 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 4 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