A Intermediate Evaluation and Management 1 Obtains focused history and performs physical examination provocative tests Neer/Hawkins O'Briens Anterior and posterior load shift Apprehension with external rotation at 0, 45, and 90 degrees of abduction lag signs Gagey test Hyperlaxity screening/Beighton criteria testing pseudoparalysis lift-off belly press scapular dyskinesia concomitant and associated orthopaedic injuries differential diagnosis and physical exam tests 2 Orders basic imaging studies radiographs AP internal rotation view external rotation view profile view of the glenoid 3 Prescribes non-operative treatment physical therapy anti-inflammatory medication 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 postop: 2-3 week postoperative visit wound check remove sutures remove sling return to activities of daily living at 6 weeks 3 month postoperative visit return to sports B Advanced Evaluation and Management 1 Interpret basic imaging studies radiographs 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 hematoma formation pseudoarthrosis intraoperative fracture of the coracoid recurrence
E Preoperative Plan 1 Radiographic evaluation (x-ray and MRI) Asess for combined labral lesions asess for glenoid-based, humeral-based, or combined bone loss on dedicated radiographic views or three-dimensional CT scan, with or without subtraction sequences. 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 Room setup and Equipment beach chair or standard OR table for lateral decubitus position 2 Patient Positioning place in beach chair 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 supervises appropriate surgical prep and draping of the field. G Deltopectoral Approach 1 Make an incision make the skin incision from the tip of the coracoid extending 4to 5 cm toward the axillary crease take the cephalic vein laterally and ligate the large medial branch 2 Place retractors 3 Dissect down to the deltopectoral interval 4 Perform deltopectoral interval dissection place a self retractor to maintain exposure dissect the interval between the deltoid and the pectoralis major using Mayo scissors abduct and externally rotate the arm place a hohmann retractor on top of the base of the coracoid H Harvesting of Coracoid Process 1 Soft tissue dissection around the coracoid maintain the arm in abduction and external rotation to tension the coracoacromial ligament Transect the CA ligament approximately 1 cm from its attachment on the coracoid using a ruler make a mark a minimum 2 cm from the tip of the coracoid partially incise at the same time the coracohumeral ligament lying deep to the coracoacromial ligament free the upper lateral aspect of the superior conjoint tendon adduct and internally rotate the arm to allow exposure of the medial side of the coracoid process release the pec minor from the attachment with electrocautery do not go past the tip of the coracoid to prevent injury to the blood supply use a periosteal elevator to remove any soft tissue from the undersurface of the coracoid this will allow visualization of the “knee” of the corocoid this is the site of the osteotomy I Osteotomy and Coracoid Graft Preparation 1 Perform the osteotomy use a 90 degree oscillating saw to make an osteotomy from medial to lateral avoid compromise of the coracoclavicular ligaments at the coracoid base abduct and externally rotate the arm again grasp the coracoid with toothed forceps 2 Release the coracoid remove any remnants of the coracohumeral ligament Perform gentle dissection medial to the conjoint tendon to allow sufficient mobilization, while avoiding iatrogenic injury to the musculocutaneous nerve place the coracoid at the inferior aspect of the wound remove any soft tissue from the coracoid 3 Decorticate the coracoid use an oscillating saw to decorticate the coracoid to expose cancellous bone place an osteotome beneath the coracoid to protect the skin 4 Drill holes place the drill template on the coracoid drill two holes using a 3.2 mm drill place the holes in the central axis of the coracoid about 1 cm apart 5 Position the arm externally rotate the arm keep the elbow by the side 6 Expose the subscapularis release for about 5 cm using mayo scissors push the coracoid beneath the pectoralis major this exposes the subscapularis muscle J Subscapularis Split and Capsulotomy 1 Identify the margins of the subscapularis identify the superior and inferior margins of the subscapularis 2 Identify the location of the subscapularis split the location for the subscapularis split is at the junction of its superior two thirds and inferior one third 3 Perform the split use cautery to create the split complete the split using a knife open perpendicular to the plane of the muscle fibers push a small swab into the subscapularis fossa in the superomedial direction place a hohmann retractor on the swab in the subscapularis fossa use a curved retractor on the inferior part of the subscapularis. extend the lateral part of the split with scalpel to the lesser tuberosity 4 Place pin hammer a Steinmann pin into the superior scapular neck as high as possible to increase superior exposure 5 Place hohman retracted replace the medial hohmann retractor with link retractor place this as medial as possible on the scapula neck place a small retractor inferiorly between the capsule on the inferior neck and inferior part of the subscapularis the anteroinferior part of the glenoid should now be easily visualized. 6 Expose the glenoid incise the anteroinferior labrum and periosteum with a knife expose the glenoid 2 cm medially from 5 o’clock to 2 o’clock in a right shoulder (a vertical distance of 2 to 3 cm) place a self retractor to increase exposure of the glenoid 7 Elevate flap use an osteotome to elevate the labral-periosteal flap from lateral to media place a hohmman retractor K Anterior Inferior Glenoid Preparation and Graft Insertion 1 Expose the anterior glenoid use a rongeur to expose the anterior inferior glenoid use a oscillating saw to decorticate the anteroinferior surface of the glenoid 2 Create a flap surface to place the graft use a 3.2 mm drill (or 2.5 mm for 3.5 mm screw) the inferior hole in the glenoid this is at the 5 o`clock position parallel to the plane of the glenoid and sufficiently medial that the coracoid will not overhang the glenoid 3 Drill the anterior cortex in anticipation of self-drilling, self-tapping screw fixation 4 Insert the graft retrieve the coracoid from its position under the pectoralis major place the graft in prepared anterior inferior prepared defect using the guide pin placement tool L Guide Pin Placement and Screw Insertion 1 Place guidepins after the graft is in the appropriate position place two parallel guide pins 2 Remove the guide pin placement tool 3 Place malleolar screws using a cannulated drilling system, drill over one guidewire place a 4.5-mm partially threaded malleolar screw into the inferior hole (tendinous end). the length of this screw is typically 35 mm but can be verified by adding together the depth of the coracoid and the depth of the glenoid hole place the screw into the already drilled inferior hole tighten into position ensure that the coracoid lies parallel to the anterior border of the glenoid with no overhang make a second drill hole through the superior hole already drilled in the coracoid measure the hole and place a malleolar screw N Capsular, Subscapularis Split and Deltopectoral Closure 1 Close the capsule copiously irrigate the wound suture the capsule to the stump of the coracoacromial ligament using number 1 dexon suture with the arm in external rotation 2 Close the subscapularis split close the subscapularis split using non-absorbable suture test the repair by internally and externally rotating the arm optional placement of platelet rich plasma at the graft site 3 Close the deltopectoral interval remove the self retractors close the deltopectoral interval using 0-vicryl 4 Superficial closure close the subcutaneous tissue with 3-0 vicryl close with a singular subcuticular 4-0 monocry suture apply steristrips place prowick sponges that have been primed with liquid betadine over the incisions
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 start PT post operative day 1 R Complex Patient Care 1 Modifies and adjusts post operative rehabilitation plan as needed post-operative stiffness 2 Order and interpret advanced imaging studies CT scan arthritis presence of defect 3 Treats intra-operative and post operative complications irrigation and debridement for infection proper infection treatment infectious disease consultation