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 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 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 rehabilitation for small or medium tears remain in a sling for six weeks with no shoulder motion allowed remove sling at 6 weeks start passive and active assisted range of motion exercises including forward elevation in the scapular plane, external rotation in full abduction, pendulum and pulley exercises limit internal rotation and shoulder extension no lifting, pushing or overhead activity rehabilitation for large tears remain in sling with no motion for six weeks at six weeks remove sling and lift arm to shoulder height only at six weeks use shoulder CPM device to regain forward elevation in the scapular plane continue CPM until three months postop diagnose and management of early complications<br /> 3 month postoperative visit for small and medium tears start strengthening exercises isometric exercises progress to isotonic exercises with a stretching program throughout for large tears initiate passive and active motion strengthening return to sports and unrestricted activity at six months diagnosis and management of late complications<br /> 4-6 month postoperative visit for small and medium tears return to sports and full unrestricted activity at 4 to 5 months for large tears return to activity at 6 months B Advanced Evaluation and Management 1 Interpret basic imaging studies radiographs proximal humeral migration on xray MRI tear size muscle atrophy labral tears arthritis subscapularis tears evaluates both the tendon and muscle quality full thickness tears show increased signal intensity at the tendon insertion on T-2 weighted images 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 Radiographic templating 2 Perform ligamentous 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 ablation wand suture anchors 2 Room setup and Equipment standard OR table for lateral decubitus position 3 Patient Positioning 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 place the arm 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 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 (optional) 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 15 Point Arthroscopic Exam 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 minute millimeter cannula using the outside-in technique I Glenohumeral Debridement 1 Debride the underside of the rotator cuff use the shaver through both the posterior and anterior portal to debride the ragged surface of the underside of the rotator cuff 2 Prepare the footprint of the greater tuberosity remove the torn tissue from the footprint of the greater tuberosity J Bursoscopy 1 Maneuver the arm maneuver the arm to the bursoscopy position use 15 pounds of weight to support the arm in 10 degrees of abduction and 5 degrees of forward flexion 2 Place the scope in the posterior bursal portal place a cannula in the anterior bursal portal 3 Evaluate the bursa K Subacromial Decompression 1 Change the irrigant to glycine 2 Place the electrosurgical cautery tool in the lateral cannula 3 Morselize the soft tissue use the cautery tool to morselize the soft tissues including the bursa and coracoacromial ligament from under the anterior 2/3 of the acrominal bone 4 Remove debris use a high speed shaver to remove the debris remove overgrown and degenerative bursal tissue 5 Perform a bony decompression use a high speed shaver to then perform the bony decompression by beginning a resection of the lateral edge of the acromion on from the anterior corner to the mid acromial area place the scope in the lateral portal and the shaver in the posterior portal to complete the resection If necessary smooth the entire undersurface of the anterior half of the acromion in a sloping fashion until approximately 8 mm is removed from the anterior edge 6 Evaluate the undersurface of the acromial facet 7 Evaluate the undersurface of the inferior facet L Cuff Repair 1 Debride the edge of the cuff back to healthy tissue 2 Prepare the bony bed use a morselized shaver to lightly decorticate the bony bed below the resting edge of the cuff 3 Create marrow vents create multiple bone marrow vents in the tuberosity using a 1.5 mm punch 4 Position suture anchors assess the proper angle for inserting the suture anchor assess the angle for the suture anchor using a spinal needle 5 Insert the anchors insert the first Revo anchor through a puncture wound lateral to the acromion and screwed down through the deltoid muscle place the tip of the anchor in the pilot hole a few mm lateral from the edge of the cartilage screw the anchor into the bone so that it is seated 3 mm below the cortical surface pass the sutures through the cuff using a curved suture needle and a suture relay place the sutures in the suture shaver triple load the each anchor with polyethylene sutures place a second suture 1.5 cm anterior to the first pass all three sutures using the shuttle technique through the edge of the cuff 6 Close the cuff lamina with sutures after all sutures are passed, withdraw the sutures in pairs out of the lateral cannula 7 Tie the sutures tie the sutures using SMC knots cut the suture to create suture tails that are 2mm 8 Assess the repair use a palpating probe to examine the repair turn the fluid pump off to observe bone marrow flow N Wound Closure 1 Irrigation, hemostasis, and drain withdraw the instruments irrigate the portals 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 5 Place sling support the patients arm in an Ultrasling 15 degrees in an ER brace
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 for small and medium tears remove for elbow range of motion exercises three or four times today a day for large tears do not remove sling and no motion for 6 weeks R Complex Patient Care 1 Modifies and adjusts post operative rehabilitation plan as needed modify for massive cuff repairs post-operative stiffness 2 Order and interpret advanced imaging studies MRI evaluates both the tendon and muscle quality tear size muscle atrophy labral tears arthritis subscapularis tears full thickness tears show increased signal intensity at the tendon insertion on T-2 weighted images 3 Treats intra-operative and post operative complications irrigation and debridement for infection proper infection treatment infectious disease consultation