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 issue explicit orders to the therapist to avoid forceful external rotation manipulation in abduction for the first 3 months weeks 6 to 12 weeks instigate a formal physical therapy program if progress is slow and external rotation is less than 35 degrees start strengthening exercises after full ROM is achieved diagnose and management of early complications<br /> 4 month postoperative visit advance to a throwing rehabilitation program 6 month postoperative visit release to full activities including contact sports provided that strength and motion are near normal and instability symptoms are absent. 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 postoperative glenohumeral noise or squeaking can occur if the knots are captured in the GH joint loss of external rotation from overtightening rupture of the repair can occur with aggressive early activities injury to the axillary nerve
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 is working 30° arthroscope fluid pump system standard arthroscopic instruments suture passing devices suture retrieving devices knot tying devices arthroscopic shavers and burrs suture anchors 2 Room setup and Equipment beach chair for lateral decubitus position 3 Patient Positioning Place in beach chair or lateral decubitus position pad any prominences 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 (if working in beach chair) support the arm in 70º of abduction and 10º of flexion using a foam shoulder traction sleeve (if working in lateral decubitus) in this position the inferior capsule is not completely relaxed, mitigating the risk of inadvertently gathering too much capsule in the axillary recess during the plication procedure, which would result in loss of abduction the view of the capsule in the inferior recess can be improved during the operation by having an assistant place his or her hand on the medial side of the arm midway between the axilla and the elbow and gently translating the humeral head in a superior direction. rotation during this maneuver can improve the view even more. G Scope Insertion 1 Outline landmarks Outline the acromion, distal clavicle, coracoid process and portal placement 2 Establish posterior midglenoid portal mark portal 1 to 3 cm distal and 1 to 2 cm medial to the posterior lateral tip of the acromion make a 4mm skin incision insert the scope sheath with a taper tip trocar into the incision and enter the joint use lateral traction to avoid damage to the articular surface insert the 30° arthroscope into the scope sheath 3 Place anterior superior portal place 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 make a small skin incision and insert a smooth operating cannula fitted with a taper-tip obturator H Diagnostic Arthroscopy and Debridement 1 Visualize the anatomy articular cartridge of the humeral head and glenoid anterior labrum and ligaments posterior and inferior labrum anterior and posterior capsule attachments to the humeral head biceps tendon inferior recess articular surfaces insertion of the subscapularis, supraspinatus, infraspinatus and teres minor 2 Establish anterior mid glenoid portal localize portal with an 18 gauge spinal needle place a 7 mm docking cannula using the outside-in technique this portal should be placed just superior to the subscapularis tendon I Glenoid Preparation and Labrum Mobilization 1 Debride the glenoid debride the anterior edge of the glenoid removing frayed tissues this gives a clear view lightly decorticate the glenoid debride degenerative labral tears, synovitis and cartilage lesions 2 Mobilize the labrum mobilize the anterior labrum and capsule completely from the neck of the glenoid using a liberator, elevator knife and shaver free the tissues down to the 6 o’clock position 3 Test tissue test the mobility of the anterior tissue by grasping the labral edge with a pincer tool and advancing it to the edge of the articular surface. if it floats freely to the surface, the mobilization is complete if the tissues are still tight, continue to work the tissues with a 1/4inch Steinmann pin as a lever until they are free to move into position up onto the cartilage surface J Remplissage Repair of Hill Sach Lesion and Suture Storage 1 Prepare fracture site prepare the posterior humeral head fracture site to expose bleeding bone by using a shaver and a curette through the posterior cannula 2 Place loaded anchor insert a 5mm “rotator cuff” style anchor loaded with 2 or 3 sutures into the inferior aspect of the humeral head defect a few mm posterior to the edge of the remaining cartilage back out the posterior cannula just outside the posterior capsule and pass a penetrating type grasper through the posterior capsule 1cm below and 1.5cm lateral to the inferior anchor 3 Retrieve sutures retrieve the second limb of the first suture with the penetrating grasper 2 cm medial to the first suture thus creating the first and most inferior mattress stitch retrieve both suture limbs into a plastic suture cover and pass it down outside the cannula to the capsule and secure them with a clamp on the plastic suture covers do not tighten the suture covers but just pass them down to the outside of the capsule the suture covers are used to keep the suture pairs together and prevent crossing and tangling as subsequent sutures are passed retrieve the second and third suture pairs with the penetrating grasper and store them outside the cannula and inside a plastic suture cover in a similar manner 4 Insert second anchor insert the second anchor 1 cm inferior and 1 cm lateral to the upper edge of the Hill-Sachs lesion retrieve one limb of the remaining suture into the AMG cannula pass the limbs of the sutures from the second anchor similar to the first and likewise store them outside the posterior cannula in a plastic suture covers complete the anterior Bankart lesion repair and tie the anterior sutures K Anchor Placement and Bankart Repair 1 Create pilot hole create the first pilot hole for the inferior-most anchor by inserting the appropriate anchor drill down the AMGP and place the tip 1.5 mm on the face of the articular cartilage of the glenoid around the 5 -5:30 o’clock position. the drill guide should be curved to direct the drill toward the center of the glenoid to avoid penetrating the inferior cortex and potential damage to the axillary nerve 2 Insert anchor insert the first soft fabric mini anchor loaded with two strands of #2 polyethylene suture into the drill guide impact it into the pilot hole seat it by pulling back on the sutures be certain that the horizontal seating line is completely below the bone this will ensure that the anchor is 2 mm below the subchondral bone remove the anchor driver by pulling or tapping straight back taking care not to toggle it retrieve one strand of suture from the anchor into the posterior cannula using a crochet hook 3 Pierce the capsule and labrum insert a 45º or 60º curved suture hook loaded with a shuttle device into the AMGP and pierce the anterior inferior capsule tissue 1 to 2 cm away from the labrum and 1 -2 cm inferior to the level of the anchor if the capsule is patulous, create a “pinch tuck” stitch in the tissue by passing the tip of the needle through a pinch of the capsule and then under the labrum 4 Maneuver shuttle to the joint roll the wheel on the suture hook handle to send the shuttle into the joint grasp the tip of the shuttle with a miniature clamp and retrieve it out the posterior cannula carefully observe the path of the shuttle to ensure that it does not trap any of the other sutures stored outside the cannula 5 Place sutures outside the PMP load the suture in the eyelet of the shuttle and carry it back through the joint, under the labrum and through the capsule by pulling back on the anterior end of the shuttle the suture strand that was pulled with the shuttle will be designated as the first post suture for tying retrieve the other two sutures (those of a different color from the on previously passed) into the posterior cannula to avoid tangling when tying the first suture apply traction 6 Tie sutures tie the first two sutures together using a sliding-locking knot followed by three half hitches alternating the post suture to ensure a secure knot retrieve one limb of the remaining suture into the AMG cannula pass the second strand of suture through the capsule and under the labrum this time exiting 5 mm above the anchor use a pinch-tuck stitch if the capsule is patulous identify which of the two sutures is located on the capsular side and use it as the post tie the second suture above the anchor, plicating the capsule and seating the labrum to the prepared bone of the glenoid 7 Place second anchor drill the second anchor hole 1.5-2 cm above the first one, usually just below the anterior mid-glenoid notch insert the second anchor and pull on the sutures to seat it tightly on occasion it is necessary to add a third anchor to complete the repair be careful not to close a normal sublabral hole or a Buford ComplexPlace loaded anchor L Tie down Posterior Remplissage sutures to Complete Hill Sachs Repair 1 Tie Remplissage sutures tie the posterior Remplissage sutures by removing the posterior cannula, reaching down the cannula with a grasping tool and retrieving the upper suture limbs and cover and pulling it into the cannula 2 Loosen sutures loosen all remaining suture covers 2 cm to prevent them from getting trapped when knots are tied 3 Tie mattress stitch tie the upper mattress stitch together using a sliding-locking knot to reduce the posterior capsule and infraspinatus to fill the Hill-Sachs defect continue tying the sutures from superior to inferior to finish the repair N Wound Closure 1 close the incisions with a single subcuticular stitch use 4-0 monocryl for closure 2 Apply steri strips 3 Place dressings place surgical sponges that are primed with liquid betadine solution over the incisions place and wrap surgical dressings over the incision cut the arm portion of the wrap to relieve pressure around the axilla and upper humerus 4 Place sling support the patients arm in a prefitted sling in 15 degrees external rotation and slight abduction
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 encourage active elbow, wrist, and hand the first day after surgery begin progressive gentle pendulum motion, isometric internal and external rotation exercises, and assisted forward elevation using a pulley after 7 to 10 days 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