Shoulder arthroscopy. [3 ed.] 9781469887630, 1469887630

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SHOULDER ARTHROSCOPY THIRD EDITION

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SHOULDER ARTHROSCOPY THIRD EDITION Stephen J. Snyder, MD

Attending Orthopedic Surgeon specializing in shoulder arthroscopy at the Southern California Orthopedic Institute, Director of the CLASroom (Center for Learning Arthroscopic Skills), Van Nuys, California

Ronald P. Karzel, MD

Attending Orthopedic Surgeon, Southern California Orthopedic Institute Medical Director, Valencia Surgical Center Valencia, California

Mark H. Getelman, MD

Attending Orthopedic Surgeon, Co-Director, Sports Medicine Fellowship Southern California Orthopedic Institute Medical Director, Southern California Orthopedic Research and Education Van Nuys, California

Joseph P. Burns, MD

Attending Orthopedic Surgeon, Sports Medicine and Shoulder Surgery Southern California Orthopedic Institute Van Nuys and Valancia, California

Michael S. Bahk, MD

Attending Orthopedic Surgeon, Sports Medicine and Shoulder Surgery Southern California Orthopedic Institute Thousand Oaks, California

David M. Auerbach, MD

Attending Orthopedic Surgeon, Southern California Orthopedic Institute Van Nuys, California With a contribution from

Marc Mirisch, PT, DPT

Physical Therapist, Director of Center for Rehabilitation, Southern California Orthopedic Institute, Van Nuys, California

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Acquisitions Editor: Brian Brown Product Development Editor: Dave Murphy Production Project Manager: David Orzechowski Design Coordinator: Doug Smock Manufacturing Coordinator: Beth Welsh Prepress Vendor: S4Carlisle Publishing Services 3rd edition Copyright © 2015 Wolters Kluwer Health 2nd Edition: Copyright © 2002 by Lippincott Williams & Wilkins. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer Health at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (­products and services). 987654321 Printed in China 978-1-4511-9170-7 1-4511-9170-7 Library of Congress Cataloging-in-Publication Data available upon request Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the author(s), editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The author(s), editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice. LWW.com

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Dedication With deepest gratitude and affection, we dedicate this book to Eleanor O’Brien. Research and education are the heart of our practice at SCOI, and you are the heart of our research and education programs.

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Foreword Time flies. You are about to start reading the third edition of Shoulder Arthroscopy. Few of us remember the first. Scarce are those who remember what it meant to do arthroscopy of the shoulder, let alone to write a book about it about 30 years ago. The truly incredible service, which can currently be rendered through arthroscopic interventions, started as an art: An application of unusual skill, knowledge, and devotion of human beings to a creative activity. For a Swiss the similarities of the peaceful revolution brought about by arthroscopy and the peaceful revolution brought about by the AO techniques of internal fixation of fractures are striking: At the basis there were few surgeons convinced that the current techniques of treatment are not really effective and bothersome for patients. The “state of the art” disrespects thoughts from outside the box and discards the potential of technological progress. To realize incredible advancements in medicine, these surgeons devote their skill, knowledge, and personality to their conviction. With respect to their environment, they have the privilege to prove that Gandhi was right: First they ignore you, then they laugh at you, then they fight you, and then you win. Arthroscopy’s role did not develop by chance: Patient interest and demand, development of skill, technological advancement in collaboration with industrial partners, assessment of results, and last but not least, teaching and teaching of what seemed to be too difficult for the community were the basis of success. For current observers, it is interesting to note that neither of the two revolutions was brought about nor greatly assisted by groundbreaking publications in journals with high impact factors or by any evidence based medicine assessments. Both came after the fact,

and in an environment that is very critical to any change, we should not forget that not every change is a progress but a progress without change is impossible. With Lanny Johnson, Harvard Ellman, Jim Esch, and very few others, Dr. Snyder has been, and is, a pioneer of shoulder arthroscopy. I gratefully acknowledge having learnt my first steps in arthroscopy from a friend who has always shared priority of values and responsibilities such as that for a family. The school he created is characterized by an extremely rational and methodical approach to assessment and treatment of shoulder problems. He has renounced on spectacle in favor of reliability and reproducibility, and used and taught arthroscopic techniques that can be reproduced and used as a very solid basis by any interested and dedicated scholar. He has described entities such as the SLAP or PASTA lesions, advanced unconventional solutions such as graft reconstructions in massive tears, he has created a learning lab, and his “Alex” shoulder model is testimony to his devotion to the teaching of shoulder arthroscopy. He has also been steady. I congratulate the SCOI authors on their book and hope that they can accept that I thank their mentor personally to have advanced shoulder arthroscopy to a point where I had a large cuff tear of my dominant arm confidently repaired arthroscopically. Christian Gerber, MD, FRCS Professor and Chairman Department of Orthopedics University of Zurich Medical Director and Head of Surgery Balgrist Hospital Zurich, Switzerland

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Foreword It is with great privilege and pleasure that I write this foreword for the SCOI Shoulder Team’s new Shoulder Arthroscopy, third edition textbook. In the Fall of 1986 while a resident in New York, I received a call from Dr. Stephen Snyder telling me that I was accepted for the Sports Medicine Fellowship in California. It was a defining moment in my professional career. Shoulder arthroscopy was evolving rapidly at that time, and little did I know that I would be joining a core group of arthroscopic leaders and pioneers that would forever change the way we treat musculoskeletal pathology. The SCOI Shoulder Team has taught us much over the years and has worked tirelessly to train and share their expertise with an extended family of dedicated physicians looking to advance shoulder arthroscopy and bioskills education. I have benefited greatly by joining the SCOI Family, a vibrant and growing cadre of over 135 fellows and many other worldwide leaders in arthroscopic surgery. Steve has been at the center, a mentor to many of us, and he has attentively taught us shoulder arthroscopy and much more; life balance, honesty, integrity, and persistence. To Steve’s credit and as a result of his distinct passion for education and sharing knowledge, he has directly impacted how we treat and how we teach. Shoulder arthroscopy has progressed dramatically because of the SCOI Group, and they have truly made a difference inspiring and mentoring many. William Arthur Ward stated so eloquently: “The mediocre mentor tells, the good mentor explains, the superior mentor demonstrates, but the great mentor inspires.”

The visionary SCOI Shoulder Team has masterfully crafted an outstanding arthroscopy textbook that comprehensively brings to life the state of the art in minimally invasive shoulder surgery. They continue to be forward thinking, progressive and creative, especially when it comes to tackling challenging treatment techniques and the shifting educational landscape. The 27 authoritative chapters are focused, rich in high-definition integrated video, and bridge the gap for all in a clear and comprehensive way, illustrating practical and cutting-edge shoulder methodologies. This monumental work will have a worldwide impact on sports medicine practitioners, shoulder experts, and advanced arthroscopists, including fellows, residents, and leading clinicians. For me this textbook is an essential resource to continue to guide me in my clinical practice and in my role in teaching fellows, residents, and medical students. I congratulate and commend the SCOI Shoulder Team and offer my thanks for their latest work, educational accomplishments, and lasting friendships. Nicholas A. Sgaglione, MD Professor and Chair Department of Orthopaedic Surgery Hofstra North Shore–LIJ School of Medicine Senior Vice President of Orthopaedics North Shore–LIJ Health System Immediate Past President, Arthroscopy Association of North America Great Neck, New York

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Preface I vividly remember the day in November 1982, more than 30 years ago, when I first viewed and marveled at the magnificent anatomy of the glenohumeral joint with an arthroscope. Although the arthroscopic instruments were crude, having no good means to support the arm, distend the joint, or perform even the most basic surgical manipulation, the experience was a life-changing event for me. I had the good fortune to join the SMOG (Sports Medicine Orthopedic Group), a newly formed orthopedic partnership that soon became SCOI (Southern California Orthopedic Institute) in 1981 as my first and only practice. At that time, the group was intensely focused on the nascent field of sports medicine with a strong emphasis on knee ­surgery— especially arthroscopy. Understandably, at that time the knee was an important joint for us to evaluate and treat with the scope since it was clearly the most common area of athletic injury and subsequent disability. But the shoulder was not far behind. My first arthroscopy teacher beyond my orthopedic residency was Doctor James Fox. I was invited to observe as he evaluated several injured knees in skiers, and was amazed at the ease and grace with which he maneuvered around the joint to clearly observe the pathology. When Jim and his partners, Marc Friedman, Wilson Del Pizzo and Martin Blazina invited me to join them in practice in Sherman Oaks, California, in 1981, it proved to be an offer to a life of personal fulfillment and professional opportunity that I readily accepted and that I enjoy and treasure immensely. The first opportunity to evaluate the shoulder arthroscopically occurred during my second year with SCOI. I don’t recall the exact patient but do remember the confusion and turmoil it caused with the operating room team. To suspend the arm, we had a pulley installed in the ceiling in the center of the room. It was my job to stand on a ladder and thread the rope. Not only was it difficult to locate a ladder but it became problematic when the bed had to be positioned in the far corner of the room to align the vector of the shoulder in the proper abduction position. Later, we would help design and develop the modern shoulder holder system. Although my foray into shoulder arthroscopy in 1982 was a singular self-guided endeavor at SCOI, I had valuable assets around the country from the likes of Drs. Lanny Johnson in Lansing, Michigan, James Esch in Oceanside, California, and Richard Caspari in Richmond, Virginia. Because there were no textbooks available, and videotape recording was still a few years off, it was necessary for us to learn the intricacies of the anatomy on our own. Our first and

probably most valuable contribution to the field of shoulder education was the development and presentation of the SCOI 15-point glenohumeral anatomy evaluation (Chapter  3). This system for performing a diagnostic shoulder arthroscopy was devised as a means to review the anatomy in a consistent, logical, and repeatable manner, thus ensuring that no important structure is overlooked. The members of our SCOI Shoulder Team continue to use this for all our cases and teach it to all our visitors and fellows. Over the years, our SCOI Shoulder Team has been actively involved in numerous projects involving the development of new surgical procedures and tools. In the early days, this was done out of necessity as there were no other acceptable alternatives for supporting the arm, regulating fluid pressure, suturing torn tissues, or fixing them to bone. Working with the many emerging arthroscopy companies, we helped create a number of novel devices that made it possible to fix torn tissues under arthroscopic visualization. Postoperative care of the patients was also hampered by the lack of suitable protective braces and dressings, and our group was instrumental in developing many of those products that enhance the post op patient experience. Since the inception of SCOI, we have had annual postgraduate sports medicine fellows and numerous physician visitors. This has been a constant source of stimulation and intellectual challenge. Our fully accredited fellowship is favorably regarded, as demonstrated by the high number of brilliant young surgeons applying and the success of those who complete the program. Often these visitors and fellows would request printed materials outlining the step-by-step methods we advocated to perform the shoulder arthroscopy procedures. The desire to share our experiences with others was the impetus for writing our first book, titled Shoulder Arthroscopy, published by McGraw Hill Inc. in 1993. This book was written as a monograph because there were no other members of the original SCOI group working specifically on the shoulder. Of course the first edition was rudimentary, but it was considered a bible by many young shoulder surgeons, especially since it included a series of VHS videotapes that demonstrated the steps of the SCOI surgical techniques. To assist in training our students to learn and perfect shoulder arthroscopy, we were often required to utilize shoulder cadavers. This was a difficult task since at that time there was no acceptable preservative for the specimens and they required freezing, making storage and preparation very onerous. To overcome this challenge, we collaborated with Pacific Research Inc., or Sawbones, to develop a line xi

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xii Preface

of realistic anatomical teaching models dubbed “Alex, The Shoulder Professor.” “Alex” has been upgraded over the years and now resembles a realistic anatomic specimen both inside and out. Our fellows and visitors are able to practice all of our shoulder arthroscopy reconstruction procedures with “Alex” in a clean, stress-free and cost-effective environment. In 2003, we published the second edition of Shoulder Arthroscopy with Lippincott Williams and Williams. In the interim between the two editions, the personal computer became available, allowing digital imaging, text authoring, and video editing to be possible. These technical advances mirrored the tremendous improvements in arthroscopic surgical equipment and techniques, as well as the understanding of anatomy and pathology. The introduction of MRI as a standard imaging tool was an important addition to the patient evaluation. Correlating arthroscopic findings with MRI helped us make the proper pre-op diagnoses and to follow up on surgical cases. These advancements, of course, rendered many of the original surgical approaches obsolete, and they were replaced with more refined procedures. Thus, the second edition was our solution to memorialize the updated SCOI philosophy. The second edition utilized the skills of a digital artist for illustrations, digital video editing for the included DVDs, and digital photographs for documentation. MRI images were used extensively to illustrate the preoperative pathology and often as documentation for post op evaluation. SCOI was a fertile incubator of new arthroscopic ideas. The support and encouragement from my partners made it possible for me to pursue my passion. Since part of the mission of SCOI includes research and education, the group has always included a sports medicine fellowship program. Not only was this an important asset for assisting in research and patient follow-up, but it is an exceptional opportunity to train and evaluate new partners for our group. The coauthors for this book, with the exception of Dr. David Auerbach, all completed the SCOI sports medicine fellowship. Drs. Ron Karzel, Mark Getelman, Joe Burns, and Michael Bahk all exhibited unique enthusiasm and aptitude for shoulder arthroscopy and are accomplished shoulder specialists as well as teachers. Dr. Auerbach is a fellowship-trained upper extremity specialist who became a member of the Shoulder Team after becoming a SCOI partner. He is an active participant in all shoulder fellowship training and teaching projects as well as a creative, skillful surgeon for the entire upper extremity. In addition to these five partners, our SCOI group has a number of additional partners who are excellent shoulder surgeons and important members of our SCOI Shoulder Team, many of whom work at outlying offices and thus were not conveniently available for the video filming and evening meetings required to complete this edition.

Our sports medicine fellowship, research department and CLASroom learning center are managed under the superb direction of Eleanor O’Brien. She is also our in-house editor for this and the previous two editions of Shoulder Arthroscopy. A brilliant woman, Eleanor has been our guiding light for the last 26 years. She is an indispensable steadfast partner, friend and “mother figure” to more than 150 fellows, hundreds of visitors, and the entire SCOI Sports Group. The impetus for this new book, Shoulder Arthroscopy, Third Edition, was the incredible expansion and improvements that have occurred in the state of the art of shoulder arthroscopy, making many of the techniques in the previous editions outdated. The basic SCOI Shoulder principles outlined previously are still followed: Efficient operating room set-up to maximize patient safety, methodical anatomy review, and documentation of the procedures. Most other areas have seen important upgrades. The new suture anchors, stitching tools, sutures, knots, biologic products such as allografts, post op dressings, and braces are significant improvements from the previous products and afford us all opportunities for improved patient outcomes. In addition, the important mission of teaching shoulder arthroscopy has been aided by the development of virtual reality shoulder simulators by Simbionix, improved Alex the Shoulder Professor models, modern Internet video sites and digital ink books with enhanced embedded videos. These innovations were never imagined when the first two books were written and are now available for all interested shoulder students to use to enhance their shoulder arthroscopy skills. I would be remiss if I failed to thank Marc Mirisch, our chief of physical therapy at SCOI. Marc has been the driving force behind the overhaul of our entire physical therapy program and has contributed to the manuscript and video segments of this work in a way that only a devoted, conscientious educator and skillful practitioner could do. Finally, it is incumbent on me, after more than 33 years of practice with my partners at SCOI, to thank them the best way I know, by paving the way to “turn over” the SCOI Shoulder Team future to them. I’m certain that this will be my final edition, but I hope they will see the value of sharing their thoughts and ideas with others and soon begin planning for Shoulder Arthroscopy, Fourth Edition. I trust that my efforts over the years will continue to enrich their professional lives as much as they have enhanced mine. I am hopeful that the experience of writing this book will serve as an ongoing stimulus for them and others who come in contact with our SCOI Shoulder Team to continue to question the status quo, rethink the accepted norms, and strive to continuously improve the field of shoulder arthroscopy. Stephen J. Snyder, MD

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Contents Foreword......................................................................................... vii Foreword.......................................................................................... ix Preface to the First Edition............................................................... xi 1 Learning Shoulder Arthroscopy..................................... 1 2 Operating Room Setup for Shoulder Arthroscopy................................................................... 7 3 Diagnostic Arthroscopy of the Shoulder: Normal Anatomy and Variations.................................. 13 4 Diagnostic Bursoscopy................................................ 29 5 Basic Techniques for All Arthroscopic Shoulder Reconstructions........................................... 37 6 Adhesive Capsulitis or Frozen Shoulder....................... 55 7 Biceps Tendon............................................................. 67 8 Superior Labrum (SLAP) Injuries and Repair............ 101 9 Laxity Versus Instability............................................. 119 10 Anterior Shoulder Instability...................................... 127 11 Instability with Glenoid Bone Loss............................. 145 12 Posterior Shoulder Instability.................................... 165 13 Evaluation and Arthroscopic Treatment of Multidirectional Instability of the Shoulder................ 181 14 Glenohumeral Osteoarthritis...................................... 195

15 Subacromial Impingement and Arthroscopic Subacromial Decompression..................................... 209 16 The Acromioclavicular Joint....................................... 225 17 Rotator Cuff Introduction, Evaluation, Imaging, and Philosophy of Repair........................................... 239 18 Calcific Rotator Cuff Disease...................................... 257 19 Partial Articular-Sided Rotator Cuff Tears.................. 263 20 Arthroscopic Evaluation and Treatment of Bursal-Sided, Intratendon, and Full-Thickness Rotator Cuff Tears Using the SCOI Row Technique.... 277 21 Subscapularis Tears................................................... 305 22 Rotator Cuff Repair with Augmentation..................... 323 23 Arthroscopic Technique for Reconstructing a Massive Nonrepairable Rotator Cuff Defect Using Acellular Human Dermal Matrix Allograft......... 335 24 Suprascapular Nerve Pathology................................. 361 25 The Shoulder Patient’s Perspective: Through the Eyes of a Shoulder Surgeon.................. 369 26 Postoperative Protocols—Physical Therapy.............. 379 27 Measuring Outcomes in Shoulder Arthroscopy......... 389 Subject Index.................................................................................399

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SHOULDER ARTHROSCOPY THIRD EDITION

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1

Learning Shoulder Arthroscopy Arthroscopy is here to stay. Over the last two decades, arthroscopy has advanced dramatically, and the industry has invested umpteen millions of dollars developing new technology, which often requires advanced arthroscopic ­ skills on the part of the surgeon. As such, it is becoming more important for both the general orthopedist and the sports medicine specialist to develop arthroscopic proficiency. While resident education has expanded the exposure to arthroscopy and development of arthroscopic skills, most graduating residents do not possess the necessary skills to perform complex arthroscopic shoulder procedures. Continuing medical education currently focuses on the understanding of concepts in orthopedics, but surgical proficiency is not assessed. It is incumbent on the individual surgeon to achieve the best skills possible. There are several avenues available to assist surgeons in attaining the training necessary to perform shoulder arthroscopy safely and effectively.

biceps stabilization, represent the more common surgical procedures requiring advanced skill. Additionally, newer ­ procedures such as arthroscopic AC joint reconstruction, Latarjet repair, and suprascapular nerve decompression are evolving procedures and require the greatest level of surgical prowess to complete. It can be difficult for a novice arthroscopist to complete these advanced procedures in a timely and effective manner. However, with study and extensive practice using models, cadavers, and courses, most surgeons will be able to develop the surgical expertise to perform these procedures and incorporate them into their practices. These procedures can be difficult, and without the appropriate proficiency, the penalty for poor technique can be severe, with short-term or even permanent harm to the patient.

c WHO SHOULD LEARN SHOULDER ARTHROSCOPY?

Residency training today has greatly expanded the use of arthroscopy, and most programs have several dedicated rotations in sports medicine and arthroscopy. Addition­ ally, other subspecialty disciplines are adding the use of the arthroscope routinely, and there is a greater comfort level with most residents when they graduate. It can be more daunting for a practicing orthopedist who is looking to expand his or her practice profile with arthroscopy. An interested surgeon today has several options to gain the requisite skills before practicing arthroscopic techniques on their own patients. A detailed understanding of diagnostic arthroscopy is mandatory and can be obtained through textbooks, ­videos, courses, and direct observation. Surgical observation may well be the best option. Observing an expert arthroscopist in his or her own operating theater provides an ideal environment for learning. Beginning with room and patient setup, the observer can obtain a detailed understanding of

As arthroscopic techniques evolve, more and more surgeons have developed an interest in shoulder arthroscopy, and if it is going to be performed, it should be performed well. All those with an interest in the shoulder should develop a basic level of proficiency and should be able to perform a thorough diagnostic exam, looking from both the anterior and the posterior portals. In addition, one should also be able to perform simple procedures such as loose body removal, joint debridement, biceps tenotomy, subacromial decompression, and distal clavicle excision. The more complex reconstructions require an additional level of surgical expertise. Instability and SLAP repairs intra-articularly, along with rotator cuff repair and

c GETTING STARTED IN SHOULDER ARTHROSCOPY

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2 SCOI Shoulder Arthroscopy

the anesthesia techniques and positioning, patient orientation with both beach-chair and lateral decubitus positions, including the use of balanced suspension, appropriate patient padding, and nursing demands. Arthroscope insertion tips and tricks and a thorough evaluation and understanding of the anatomy can be garnered in such a setting. To master arthroscopic techniques, it is important to develop a basic foundation and then build on it in a systematic manner to advance one’s surgical technique.

Print Options: Textbooks There are several well-written textbooks available with detailed information on shoulder arthroscopy. There are shoulder textbooks, which include arthroscopy sections, arthroscopy texts, which include shoulder chapters, and, finally, texts that are dedicated solely to arthroscopic ­shoulder techniques. Within this latter category, there are essentially two types of books available: those compiled by principal editors, which include chapters written by leaders in the field from various institutions who provide very different viewpoints chapter to chapter, and those written by a single author or institution, offering a written mentorship philosophy, which may be more approachable for the ­student. By using a mentorship text, the principles remain the same chapter to chapter, and this allows the surgical approach to develop in a logical order, which can be ­followed and learned by the student.

Print Options: Journals and Periodicals As arthroscopic shoulder techniques have developed, they have become accepted as the standard of care, and the number of peer-reviewed published journal articles has ­ increased dramatically. The Journal of Arthroscopy and Related Surgery continues to be the leader for shoulder arthroscopy printed information and is provided as a member benefit to all members of the Arthroscopy Association of North America (AANA). It includes peer-reviewed articles, technical notes, systemic reviews, case presentations, and abstracts from the AANA annual meeting. The international arthroscopy experience has grown dramatically in recent years, and the Arthroscopy journal has welcomed the international investigators and included several articles from all over the world, enhancing its value significantly. The Journal of Shoulder and Elbow Surgery is the ­preeminent periodical relating to all aspects of shoulder and elbow surgery, with each article undergoing rigorous peer review. In the past several years with William Mallon as Editor, the journal has increased its publication of shoulder arthroscopy articles, expanding its value to arthroscopic shoulder surgeons. The American Journal of Sports Medicine also commonly includes shoulder arthroscopy articles relating to athletes of all levels. As well, the Journal of Bone and Joint Surgery, the premier American orthopedic journal, has recently expanded its inclusion of excellent shoulder articles detailing the value and importance of shoulder arthroscopy. The AAOS and Orthopedics Today are monthly periodicals that publish articles highlighting activity at recent meetings and within the American Academy of Orthopaedic Surgeons. There are often articles on emerging topics

by invited guest authors, round-table discussions, and pointcounterpoint debates that are well-presented and offer stimulating reading.

Video Options Since the beginning of modern shoulder arthroscopy, ­capturing video has been a common and extremely valuable tool to facilitate the exchange of ideas and learning. DVD media has become readily available; with the explosion of digital materials, personal tablets, and smartphones, learning shoulder arthroscopy has never been easier and can take place just about anywhere. This has been the most dramatic advance in the past 5 years and will likely become the primary source of learning and ongoing education in the future. The educational resource centers of the AAOS and AANA offer a number of video publications, which provide detailed demonstration of surgical techniques in a peer-reviewed ­format and can be very valuable for the arthroscopy student. The Internet offers a wealth of information, and orthopedic education is no exception. Search engines can provide hundreds and even thousands of sites that offer shoulder arthroscopy information. Online options also exist for video review through sites such as YouTube, but Vumedi.com has emerged as the leader. It is the most widely used online resource for orthopedic surgeons looking to get instant access to technical information about shoulder arthroscopy. It seeks to become the de facto location for technique videos and provides an outstanding resource for live and archived discussion to provide ongoing learning for a registered orthopedic community. It has become an invaluable resource for many surgeons who seek specific technique information and provides an easy way for orthopedists to learn and review techniques and plan for surgery. In addition, AANA and the Arthroscopy journal have recently launched arthroscopy techniques as an electronic online journal that provides peer-reviewed, clinically relevant, and innovative techniques. Another option is G9MD, which offers a rebroadcast of meetings and seminars. A student can register online and view a rebroadcast of a meeting at a convenient time and location. The Shoulder Team at the Southern California Orthopedic Institute (SCOI) has developed numerous videos, which will accompany this text, and additional videos are also available through Southern California Orthopedic Research and Education (SCORE), the Center for Learning Arthroscopic Skills (CLASroom), and the SCOI educational channel at Vumedi.com. These videos are updated frequently and detail the latest shoulder arthroscopy techniques used at our center.

c LEARNING SHOULDER ARTHROSCOPY The CLASroom The CLASroom is located in our main office in Van Nuys, California. It is a unique comprehensive center designed to facilitate learning all aspects of arthroscopy and emphasizes the most common shoulder techniques performed today. The CLASroom was opened in June 2001 as a teaching tool and has proven itself to be invaluable to those seeking to learn

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Chapter 1

/

Learning Shoulder Arthroscopy 3

Figure 1‑1. SCOI

CLASroom. The SCOI CLASroom o­ ffers several options to help surgeons master arthroscopic skills.

shoulder arthroscopy. It offers a variety of teaching options to any student: resident, fellow, or surgeon who desires to become a better arthroscopist (Fig. 1-1). Video Stations Three video stations are available and are fully equipped for hands-on surgical practice. Learning and then perfecting a surgical procedure can be difficult. To learn a technique, the steps must be repeated over and over until the moves are well-understood and easily performed. Watching an expert arthroscopist will make a procedure look simple; however, the true difficulty is garnered by observing a ­novice surgeon attempting the same maneuvers. Most skilled technicians first learn, then rehearse and repeat the steps needed to perform and perfect a task. The learning begins with observation and continues with an apprenticeship until the steps can be repeated skillfully on a regular basis. It is at this point that the apprentice will be able to perform the task independently, and this is very ­similar to the approach used for surgical training. Each August, five residency program graduates arrive at SCOI feeling confident in their training and arthroscopic skills. They begin their fellowship training and almost ­immediately realize how much more there is to learn about arthroscopy. They start their education observing surgery and are encouraged to use the CLASroom to perfect their individual skills. It has made an enormous difference in our approach to fellowship training and has allowed our fellows to more rapidly advance in their hands-on interaction with patients. The steps of many arthroscopic procedures can be ­effectively performed on a model, and it is for this reason that we have developed the ALEX shoulder professor in conjunction with Sawbones, Inc. (Pacific Research, Vashon, WA). ALEX is a shoulder surgical model named in honor of Dr. Alessandro Castagna, a leading shoulder surgeon, educator, and friend to SCOI from Milan, Italy. Dr. Castagna inspired Dr. Snyder to develop the model, and it has been perfected through many redesigns to assist in surgical training (Fig. 1-2). The current model closely resembles an actual shoulder in size and shape. There is a fleshlike outer shell, which allows surgical portals to be created and requires the use of an arthroscope for training. The intra-articular

and subacromial anatomy have been recreated, affording a ­surgeon the opportunity to practice many different procedures, including anterior and posterior shoulder instability, capsular plication for multidirectional instability, SLAP lesion management, superior and anterior rotator cuff repair, and biceps tenodesis. Once proficient with the multiple steps on the model, the student can then advance to perform the procedures in a cadaver lab and exercise those skills more effectively in surgery as well. In collaboration with Sawbones, we have recently ­developed a portable arthroscopy training kit. The Portable Arthroscopic Camera System (PACS) or “Alex” Cam has been designed with a USB camera and USB light source that is plug and play with both Mac and PC platforms (Fig. 1-3). It provides the student with a realistic learning environment, operated in conjunction with the ALEX model, which can now be used wherever computer access is available. Arthroscopy Simulation For several years, we have been actively involved with ­progressing arthroscopic simulation to serve as a training tool, and we strongly believe that this will eventually become a common tool to learn arthroscopic skills. There has been great advancement in the fields of laparoscopic and gynecologic surgery, and several companies are now investing in the development of arthroscopic simulators. Currently, the simulators are useful for 3D orientation, which can improve hand-eye coordination, triangulation skills, and identification of anatomy. The technology should progress to be able to perform actual procedures in the future.

Other Arthroscopy Educational Opportunities Educational Courses with Cadaver Labs Throughout the year, there are many courses that focus on arthroscopic education using cadaver material. These are available through private meetings and orthopedic societies alike, with several of the large orthopedic equipment companies also offering professional education courses focusing on their individual products. Once the surgeon has studied the steps of the procedures, practiced and perfected knot tying, and mastered

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4 SCOI Shoulder Arthroscopy

FIGURE 1-2.  ALEX model. The ALEX model provides an excellent opportunity for practicing shoulder arthroscopy.

FIGURE 1-3.  The Portable Arthroscopic Camera System.

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Chapter 1

the procedures multiple times on ALEX models, attending a cadaver course can be extremely valuable. These labs ­provide human tissue to perfect the steps safely. The lab will provide specimens; however, the quality of the tissue can vary as many of them are from the elderly, which may be arthritic, stiff, and not ideally represent the pathology. ­Creating the lesion can be time-consuming and difficult, but, nonetheless, practicing on a cadaver remains a great option for a “final examination” before moving to the operating room. The cadaver labs are also a nice option for testing new equipment or techniques. Several courses provide excellent faculty and equipment and should be highly considered: 1. The Orthopedic Learning Center (OLC) in Rosemont, Illinois, is easily accessible from the Chicago O’Hare airport. The OLC is an outstanding facility devoted exclusively to education and focuses on arthroscopy. The AANA runs the OLC and offers several courses throughout the year. The AANA courses are typically 3-day sessions, which use top-level Master Instructors and outstanding lab support staff in a small group s­ etting where there is adequate time to practice and work with the faculty. 2. The Napa Course is an excellent annual course run by the physicians of SCOI and chaired by Dr. Mark Getelman and Dr. Wesley Nottage of the Sports Clinic. This course is devoted to hip arthroscopy and comprehensive shoulder management, selects its faculty to address controversial issues with thought leaders on all subjects, and strives to provide several points of view on controversial topics. In addition to the didactic presentations, cadaver lab sessions are available with outstanding faculty to teach many advanced arthroscopic techniques. 3. The San Diego Shoulder course is held each June in San Diego. This is perhaps the best and most comprehensive venue to study shoulder arthroscopy. This course was started by Dr. James Esch in 1983 and

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Learning Shoulder Arthroscopy 5

recently celebrated its 30th anniversary. It has grown enormously and continues to improve every year. The lectures are up-to-date with outstanding faculty, stateof-the-art audiovisual support, and incredible laboratory support faculty. The course offers both model and cadaver lab sessions to allow a comprehensive learning environment and also provides a great social educational experience. 4. The AANA also hosts the Fall Course every November. As the premier association for arthroscopy education, the AANA runs a comprehensive course, which does an excellent job of addressing not only shoulder, but knee, hip, ankle, and wrist and elbow arthroscopy as well as knot tying. Registrants can choose to attend lectures only or various laboratory and focus demonstrations as well. 5. The AAOS in association with the American Orthopaedic Society for Sports Medicine (AOSSM) and American Shoulder and Elbow Surgeons (ASES) also offers many specialty courses with excellent opportunities to learn shoulder arthroscopy. Some of these courses ­include labs at the OLC that can also be considered. Continuing Education In today’s digital age with rapid technologic advancement, there is a wealth of information available on the Internet. Search engines can deliver thousands of sites that provide shoulder information and the rebroadcast of courses is available for study as well. The educational process never stops, and we often say that we are doing procedures today that we did not learn during our training. We must continue to study, learn, and innovate to keep the field advancing for ourselves and for our patients. We encourage you to read, watch ­videos and Internet webinars, attend courses, and visit the CLASroom in Southern California as well as surgeons throughout the world. Use the plethora of resources available and challenge yourself to be the best surgeon possible. Classroom

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2

Operating Room Setup for Shoulder Arthroscopy c INTRODUCTION

c OPERATING ROOM LAYOUT

Shoulder arthroscopy is a team event. It is important that all those involved be aware of the unique requirements, including equipment, anesthesia, patient positioning, and surgical technique to ensure that the case is performed with maximum efficiency and patient safety. In our operating room, each team member is expected to be familiar with all the aspects of the procedure and not just his or her primary task. This chapter is intended for use not only by the surgeon and assistant, but also by the entire operating room staff, including the nurses, anesthesiologists, and scrub technicians. If the surgeon is new to a hospital or surgery center, we suggest that an “in-service” be held with the entire team before undertaking the first shoulder arthroscopy case to ensure that each team member is aware of the steps of the procedure and the specific requirements peculiar to the case. We also suggest that this chapter be copied and distributed as a handout for all team members in preparation for the meeting and as a reference for future cases. In addition, the companion video is an ideal training tool for the operating room staff.

The operating room table is situated in the center of the room but angled so that the anesthesiologist is positioned approximately 45 degrees toward the anterior side of the lateral-­ positioned patient. This gives the surgical team unobstructed access to both the anterior and the posterior shoulder (Fig. 2-1). The video and shaver equipment stack is situated on either a movable video cart or ceiling-mounted boom positioned on the anterior side of the table facing the surgeon (Fig. 2-2). The basic equipment on the video stack includes a 26-inch HD video monitor, an HD camera box, a light source, a shaver console, a digital documentation/DVD burner, and a photo printer. Along with a main back table for equipment, two ­additional Mayo stands are utilized. One Mayo stand is ­positioned just behind the surgeon and assistant on the ­posterior side of the table. This tray holds basic instruments: graspers, a hemostat, switching sticks, probe, a marking pen, and a kidney basin. The kidney basin is kept on this stand to keep all sharp instruments, such as the scalpel and spinal needle (Fig. 2-3). When the surgeon finishes using any sharp tool, it is placed back in the basin. Using the “sharps basin” in this manner minimizes the risk of injury to the scrub tech or surgeon that might otherwise occur when sharp instruments are handed back and forth in a dimly lit operative suite. The second Mayo stand is positioned on the front side of the OR table where it can be accessed at the level of the patient’s chest. It is covered by a sterile towel and carefully moved to this position by the scrub technician after draping of the patient. In this location, the surgeon and assistant can reach some of the most frequently used tools for the operative procedure, obviating the need to wait for the scrub tech to pass them. This tray initially holds the arthroscope, its light cord, the mechanical shaver, the suction tubing, and the radio-frequency device (Fig. 2-4).

c OPERATING ROOM ENVIRONMENT Any standard operating room at least 30 × 30 feet is sufficient for shoulder arthroscopy. If there are exterior ­ windows in the room, they should be covered with blackout blinds to darken the room to ensure optimal video viewing. Ideally, there would be a source of supplemental lighting that is reflected off the ceiling to indirectly illuminate the surgical field. The walls of the room should be finished with nonglare materials to diminish the reflection on the video monitors.

7

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FIGURE 2-1.  The operating table is positioned in the center of the room, prepared with the positioning aids: Vacupak beanbag, head support, leg compression stockings, axillary roll, and pillows. The arthroscopy tower is positioned across from the surgeon’s side of the table.

FIGURE 2-3.  The first Mayo stand is prepared with basic instruments and is positioned behind the surgeon on the operative side of the table.

FIGURE 2-2.  The arthroscopy “tower”: The video and power equipment

stack holds all of the recording, monitoring, and documenting equipment along with the shaver power source.

FIGURE 2-4.  The second Mayo stand holds instruments at the front side of the patient: the arthroscope, shaver, and radio-frequency device.

8

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Chapter 2

Arthroscopic Fluid Irrigation and Pump System The arthroscopic pump system is placed next to the video cart. There should be adequate space between them to minimize the risk of fluids splashing onto the electrical equipment in the video cart. The pump apparatus is held on a stand within easy view of the surgeon, usually toward the foot of the table. We have used various gravity and arthroscopic pump systems for shoulder arthroscopy and have found a good pump to be an invaluable asset. The preferred pump for our purposes is the Linvatec 87k model (Largo, FL) (Fig. 2-5). This pump system can accommodate a number of different options for inflow, outflow, and fluid pressure monitoring, quickly and automatically controlling conditions within the operative site to help ensure optimum visibility and distension. The pump will automatically monitor and maintain the selected values for pressure and flow rate, independently of one another, alarming or even shutting down if pressures increase significantly at the tip of the arthroscope. This is an important safety factor when compared with other systems designed to sense pressure from a cannula located away from the pump inflow line. In these other systems, the tubing can be kinked or the cannula blocked by synovium, causing it to sense an inaccurately low-pressure reading, and possibly pump a dangerous amount of fluid into the body. An outflow cannula is connected to the outflow tube included with the tubing set. This drainage line passes back through a pinch valve at the pump box when the tubing cassette is loaded. This arrangement is advantageous because it eliminates the need for suction and hence negative pressure when draining the joint. When one uses a burr during subacromial surgery, the bone debris can be evacuated using the outflow cannula connected to the drain tube with only minimal suction through the burr motor. Because there is no negative suction pressure, the outflow is gentle, maintaining a little positive back pressure, thereby minimizing bone bleeding and lessening flow turbulence. In addition, there is no fear of the outflow being plugged by debris as often occurs when suctioning exclusively through the burr. The remote control for the pump is positioned in easy reach of the surgeon on the front Mayo stand. The fluid flow

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Operating Room Setup for Shoulder Arthroscopy 9

and pressure are adjusted frequently during the case to maintain optimal visual clarity while using only the minimum pressure necessary to control bleeding. The 3-L irrigation bags are hung near the arthroscopic pump.

Shoulder Traction Equipment Supporting the shoulder in the proper position for shoulder arthroscopy requires a special system designed for safety and efficacy. It must apply gentle, balanced support of the arm with just the required amount of traction, be simple to adjust for both arthroscopy and bursoscopy positions, and be easy to install and remove from the OR table. We prefer the 3-Point Shoulder Distraction System (Arthrex, Naples, FL), placed on the nonoperative side of the table and set such that it will provide approximately 70 degrees of abduction and 10  degrees forward flexion while in the glenohumeral position (weight on the white cable), and approximately 15 degrees of abduction and 5 degrees of forward flexion in the bursoscopy position (weight on the yellow cable). We do not use the red distraction cable routinely, but it can be helpful in providing some lateral traction and rotational control in certain cases. Variable degrees of abduction can be achieved by moving the traveling pulley along the upper boom arm. There are several arm suspension sleeves currently available. We prefer either a S.T.a.R. Sleeve (Shoulder Traction and Rotation, Arthrex, Naples, FL) or the Gelzone Suspension Sleeve (Ventura, CA). The Gelzone can be applied unsterile before draping, allowing the arm to be placed in suspension without having to be manually held while the circulating nurse preps (Fig. 2-6). It can later be draped with a sterile towel and sterile 6-inch Coban overwrap. The ­Gelzone can be cleaned and reused, and does not rely on significant compression to prevent slippage—its soft v­ iscous silicone layer allows a reliable suspension hold without ­having to tightly wrap the arm, minimizing the risk of t­ransient ­postoperative neuropraxia.

Floor Suction Drainage Mats Despite using specialized shoulder arthroscopy drapes with fluid collection pouches, there will always be an amount of water that spills onto the floor. It can be helpful to have a ­suction system to collect the fluid from the floor to maintain safe and comfortable footing for the surgical team and facilitate room cleanup between cases. The product we ­prefer is the fluid collection suction floor mats called Aqua Vac (Arthro Plastics, Chagrin Falls, OH). Two mats are employed, one at the head end of the table and one along the posterior side. They are connected with a Y tube to a suction system located at the head of the table with the tubes positioned away from the area where the operating team stands.

Patient Positioning Aids

FIGURE 2-5.  The Linvatec 87k arthroscopy pump has advanced safety and monitoring features.

Because the patient will be maintained in a lateral ­decubitus position for arthroscopy, several unique positioning aids should be available (Fig. 2-1). A 3-foot-long Vacupak ­“beanbag” size 32 (Olympic Medical, Seattle, WA) is placed on the table with the base of the U-shaped end at the level of the patient’s scapula. A 1-L plastic bag of IV solution

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10 SCOI Shoulder Arthroscopy

FIGURE 2-6.  It is easier on the operative staff if the arm can be suspended in position prior to prepping and draping. The arm can later be draped in a sterile fashion.

wrapped in a cotton towel constitutes a useful “axillary roll.” A foam head-and-neck support with a section cut out for the patient’s ear should be available for use by the anesthesiologist once the patient is turned on his side. Additionally, four soft pillows are employed under and between the patient’s legs to prevent strain on the hips and knees and avoid excess pressure on the bony prominences. Foam padding is helpful to protect the dependent peroneal nerve, the ankles, and the elbow and wrist of the contralateral arm. Once the room setup is complete and the instruments and arthroscopic equipment are ready, the patient may be brought into the operating room.

c PATIENT PREPARATION IN THE OPERATING ROOM BEFORE ANESTHESIA The patient is positioned on the operating table with the “U” portion of the beanbag at the level of the axilla. A single cotton sheet covers the beanbag for comfort and is also useful when lifting the patient while turning to the lateral position. The patient’s head rests on a comfortable pillow until he is asleep, at which time a foam head-and-neck cradle is substituted for better and less obtrusive support. The head and neck should be positioned in a neutral, not tilted, fashion to prevent cervical or brachial plexus strain. Warm blankets help keep patients comfortable and relaxed. Two arm boards are attached to the table to afford comfortable support of the upper extremities. The OR lighting should be subtle and the surgical spotlights must never be directed into the patient’s eyes. Cardiac monitor leads are attached to the chest well away from the surgical site but never on the dependent thorax where they will create pressure points when the patient

is positioned on his side. When the team is all set and the surgical equipment is prepared, general endotrachial anesthesia is induced.

c PATIENT POSITIONING AND SURGICAL PREPARATION AFTER ANESTHESIA As soon as the patient is asleep and the endotrachial tube is secured, the team prepares to turn the patient to the lateral decubitus position. Four team members are required to turn the patient safely: the anesthesiologist for the head, the surgeon and assistant for the anterior and posterior trunk, and a nurse for the legs. The arm board is removed from the posterior side of the table and the one on the front is repositioned to the maximum upper limit of the Clark rail and angled upward 30 degrees to accommodate the dependent arm position after the turn. The anesthesiologist directs the turn. He supports the head, detaches the anesthesia circuit from the endotrachial tube, and directs the others to lift the patient on his count. The patient is elevated from the table using the draw sheet and moved a few inches toward the posterior side of the table before gently turning him to the lateral position with the surgical shoulder uppermost. The axillary roll is positioned in the “U” of the beanbag to support the thorax and prevent pressure on the dependent shoulder and axilla (Fig. 2-7). The anesthesia tubing is reconnected, the breath sounds are carefully evaluated, and the positioning aids are installed. Place the foam padding below the dependent ankle, elbow, and peroneal nerve, and install the pillows between the thighs and legs. Flex the knees and hips to a comfortable balanced position, and mold the beanbag around the torso to maintain

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Chapter 2

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Operating Room Setup for Shoulder Arthroscopy 11

table is rotated 45 degrees posterior to allow room for the surgeon to stand near the patient’s head.

Examination for Motion and Stability With the patient in the lateral position, test the shoulder for range of motion and ligamentous stability. If there is any question of instability, perform the examination with video recording to document the status of the ligaments on the permanent video record. If the operating room is not equipped with an overhead camera, use the arthroscopic camera without the arthroscope for the recording.

Patient Sterile Preparation

FIGURE 2-7. The

axillary roll is placed below the dependent thorax to ­reduce pressure on the axillary structures.

the patient in the lateral position tilted posterior 20 degrees. Deploy the beanbag by applying suction to deflate it. Safety straps are attached across the table to stabilize the patient. Four pillows are used to support the lower legs: two between the legs and the table, and two between the upper and lower legs. Sequential compression devices are also used to minimize the risk of deep venous thrombosus. The operating

The Arthrex 3-point shoulder traction unit is attached to the Clark rail of the operating table on the side which the patient will be facing, contralateral to the surgical side (Fig.  2-8). The arm is then placed in the Gelzone and suspended in approximately 10 pounds of traction on the white cable. The surgical site is then initially isolated using the plastic U-drape around the shoulder and the rectangular drape to connect the legs of the U-drape. The exposed arm, shoulder, and hemithorax are then prepped without having to hold the arm up. If the chosen prep solution remains wet or contains flammable alcohol, any excess needs to be removed and allowed to completely dry. The surgeon and the scrub tech then apply the surgical arthroscopy drapes. The specialized drapes must seal on the skin to protect the patient and anesthesiologist from

FIGURE 2-8.  A boom for suspending the shoulder in the lateral position will provide balanced glenohumeral

support in several variable degrees of abduction and flexion. The Arthrex 3-point shoulder distraction system (points 1, 2, 3) is attached to the table on the side opposite the surgeon. The angle of abduction can be adjusted by moving the traction pulley (arrow) up or down along the boom.

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12 SCOI Shoulder Arthroscopy

FIGURE 2-9.  The patient is prepped and draped for shoulder arthroscopy. The specialized shoulder drapes keep the surgical fluids off the patient and the operating table. A towel is folded into a pouch, or “bandana” (B), and wrapped into the Coban as a place to keep basic instruments (grasper, switching sticks) close at hand. contamination with surgical fluids. Fluid is collected in pouches anterior and posterior on the drape and drained by gravity into a large container or bucket adjacent to the head of the table, where it can be monitored and emptied as needed by the circulating nurse (Fig. 2-9). The arm is draped with a thick sterile towel wrapped lengthwise, and then overwrapped with a 6-inch self-adherent Coban wrap. Another towel can be folded into a pouch and wrapped into the Coban along the upper arm. This “bandana” serves as an

additional place to keep basic instruments (switching sticks, graspers) close at hand. Appropriate bony landmarks are then outlined on the shoulder with a sterile marker. Prior to incision, a surgical “timeout” is called: the correct patient, procedure, and surgical site are confirmed. Surgeon initials on the extremity are confirmed as correct and visible. Prophylactic antibiotics are confirmed as being given, and the OR Setup procedure begins.

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3

Diagnostic Arthroscopy of the Shoulder: Normal Anatomy and Variations c INTRODUCTION The SCOI “15-point system” for performing a complete diagnostic arthroscopic evaluation of the shoulder was developed by the authors in 1984 and first presented at the annual meeting of the Western Orthopedic Association in 1986. The purpose for establishing a stepwise checklist for the diagnostic shoulder arthroscopic exam was to institute a standardized intuitive arthroscopic routine that would ensure the strict performance of a uniform comprehensive evaluation of all anatomical structures in the shoulder. Another equally important purpose of this formal exam is to familiarize the surgeon with the skills needed to visualize the shoulder from both anterior and posterior portals. Unless he or she is comfortable with routinely viewing from both anterior and posterior portals, it will be difficult for them to comfortably operate from both vantage points. The steps of the 15-point exam are designed to follow a smooth, natural progression around the shoulder joint, pausing at each important anatomical area for assessment and, when necessary, palpation. The typical exam requires about 4 minutes of surgical time but ensures that no significant pathology will be missed. Once the video scope became available, we began recording every shoulder arthroscopy exam, both for our own records and also for our patient to review to help his or her understanding of their particular surgery. Having a standard, consistent video-recorded exam guaranteed that no pathology would ever be overlooked. Additionally, as our library of video cases expanded, these records became a valuble source of reference information, affording us a voluminous data bank for future studies such as that of the Buford complex, rotator cuff pathology, and the superior labral changes related to patient age.

The 15-point SCOI arthroscopic shoulder exam is i­ deally performed with the patient in the lateral decubitus position on the operating table and with the arm supported in 70 degrees of abduction and 15 degrees of forward flexion. The diagnostic procedure consists of visualizing and video recording all of the anatomic features in the glenohumeral joint and subacromial space from both the anterior and ­posterior portals. In this chapter, we will describe the techniques we use to visualize the normal glenohumeral anatomy, as well as the common and sometimes confusing normal variations that may be encountered.

c PHYSICAL EXAMINATION OF THE SHOULDER Physical

A complete physical examination of the shoulExam der is always performed in the clinic. This always includes observation of the bony and muscular anatomy, palpation of all areas of the shoulder, both active and passive range of motion and specific tests for muscle strength and joint stability.

c SURFACE ANATOMY OUTLINE With the arm prepared for surgery and suspended in ­traction, outline the surface anatomy. Palpate the supraclavicular fossa, bordered anteriorly by the clavicle and the AC joint, posteriorly by the spine of the scapula and laterally by the acromion. Outline this area with a sterile skin-marking pen. 13

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14 SCOI Shoulder Arthroscopy

FIGURE 3-1.  The skin outline of the bony shoulder anatomy should be placed along the inferior edge of the clavicle, acromion, and scapular spine. The orientation line begins at the posterior edge of the AC joint and extends laterally down the arm. Next, trace the acromial and clavicular outlines. It is important to realize that when these reference lines are drawn, they should be “around the corner” and thus on the inferior ­surface of the bone and not on the most superficial subcutaneous bony prominence. In other words, the important ­anatomical reference point is the inferior margin of these bones, because that is the area from which the entry points and surgical ­incisions for the joint and bursa are estimated. To locate the correct position, use a “pincher”-type grasp. Place the thumb in the supraclavicular notch and use the index ­finger to feel for the inferior aspect of the acromion beginning at the posterior lateral angle. Once this area is located, draw an ink dot on the skin at the inferior edge of the bone. Define the remainder of the lateral border of the acromion with the index finger, placing another dot below the center point of the lateral edge and another below the anterior lateral corner. Connect the dots to define the lateral acromial border. Next, outline the S-shaped anterior edge of the clavicle to its midpoint. Place all four fingers of the anterior hand on the clavicle, using the fingertips to determine the location and shape of the bone. Complete the outline by drawing the scapular spine again by placing the tips of three or four fingers under the edge to determine the proper location. Begin from the mark at the posterior lateral angle of the acromion and continue medially to the middle of the scapula. Mark out the AC joint beginning at its posterior edge, located at the anterior margin of the suprascapular notch. Its direction can usually be identified by palpation and typically angles approximately 60 degrees in a lateral direction. Beginning at the posterior edge of the AC joint (the anterior edge of the supraclavicular fossa), draw a line that crosses perpendicular to the lateral border of the acromion and extends distally 5 cm down the arm. This reference line divides the acromion into an anterior two-fifths and p­ osterior three-fifths. Beneath the defined anterior acromion lies the subacromial bursal cavity containing the biceps tendon in the rotator interval anteriorly and the supraspinatus attachment site area laterally. The posterior bursal curtain is located just posterior to this orientation line, and the AC joint is at the medial edge. The orientation line is helpful as a reference

when creating the lateral subacromial-operating portal for decompression and rotator cuff repair procedures (Fig. 3-1).

c GLENOHUMERAL ARTHROSCOPY Creating the Posterior Mid-Glenoid Portal The first step in performing the 15-point evaluation of the glenohumeral joint is to create the posterior mid-glenoid portal (PMGP) by inserting an arthroscopic cannula. To choose the insertion point, palpate the posterior shoulder anatomy and ballot the humeral head, rocking it in an anterior to posterior direction to sense the location of the joint line. The position for the portal should be approximately 1 cm lateral from the joint line (to avoid injuring the labrum) and cannot be simply measured from the surface anatomy. The entry point should be determined after considering both the thickness of the soft tissues around the shoulder and the size of the bony anatomy. In the average-sized individual, the entry point is approximately 2 to 3 cm inferior and 1 to 2 cm medial from the posterolateral acromial angle. For patients with thicker tissues or larger bony structures, the point will be further inferior and medial. Make a small stab wound through the skin with a #11 knife blade following the direction of the skin lines. Do not attempt to pierce the muscular tissues or capsule at any time with the knife for fear of injuring the articular cartilage or cutting a blood vessel. Insert the arthroscopic cannula fitted with a tapered-tip obturator through the posterior skin incision and through the muscle until the posterior humeral head is palpated (Fig.  3-2). With the opposite hand palpating the anterior ­surface of the shoulder joint, ballot the humeral head back and forth until a sense of the joint line location is appreciated. Direct the cannula to slide medially off the humeral head to feel the step-off between the head and glenoid. Work the cannula so that it punctures perpendicular through the capsule, usually feeling a definite pop. A common error making the initial PMGP is to insert the c­ annula at a point too lateral or proximal. Remember that the joint line is located inferior

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Chapter 3

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Diagnostic Arthroscopy of the Shoulder: Normal Anatomy and Variations 15

FIGURE 3-3.  Insert the anterior cannula over a guide rod and scope sheath and into the joint to create the AMGP. FIGURE 3-2.  Insert the arthroscopic cannula into the PMGP using the taper tip of the obturator to palpate the articular surface of the humeral head. and medial to the posterolateral acromial corner. If difficulties are encountered, inject 30 CCS of ­surgical irrigant into the joint via the chosen portal site to confirm the position. Never use excessive pressure or employ a sharp trocar in the scope cannula for fear of penetrating the soft bone in the back of the humeral head, damaging the ­articular surface, the labrum, or the posterior rotator cuff. Once the capsule is punctured, insert the scope, turn on the fluid flow, and confirm that the portal is truly in the joint and not in the bursa. Occasionally the initial visualization may be poor due to bleeding, and joint lavage may be necessary. Remove the scope from the arthroscopic cannula and place a thumb tightly over the outer opening. Turn on the pump to distend the joint and intermittently release and apply the thumb over the opening. Raise the pump pressure temporarily to tamponade the bleeders. Always remember to decrease the pump pressure as low as possible following the lavage and throughout the case to avoid unnecessary fluid extravasation into the soft tissues. After a few lavage cycles, the visual field is usually clear. If not, check that the patient’s blood pressure is reasonably controlled (4 to 5 mm in depth without significant glenoid bone loss), we will consider the remplissage if there is concern that the HS lesion will potentially remain within the glenoid track following standard Bankart repair. We begin by mobilizing the Bankart lesion, as discussed earlier. Once the lesion is fully mobilized, we use a grasping clamp to reposition the labrum to the location where the repair will be completed. With the labrum in its reduced position, the HS lesion is reevaluated. Typically, the HS lesion will rotate essentially out of the surgical viewing field, signifying that it will not likely articulate or engage through ROM. If, however, the HS lesion remains visible or approaches the anterior glenoid with humeral rotation, we will then perform the remplissage as well. The timing of the remplissage remains controversial, with some authors recommending it be completed after the Bankart repair, while others advocate that the remplissage be ­performed first. We believe that the best time to do the remplissage is immediately after the completion of the anterior mobilization, but before the labral repair, when it is easiest to view. With the scope in the anterior-superior viewing portal, it is very

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Chapter 10

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Anterior Shoulder Instability 141

FIGURE 10-28.  Illustration demonstrating the preparation

of the HS lesion.

easy to see the lesion and, prior to the Bankart repair being completed, the HS lesion is very easy to access. We work through the standard posterior portal and begin by preparing the HS bed. Ring curettes and the motorized shaver are used to create a bleeding bed for repair ­(Fig.  ­10-28). One to two suture anchors are inserted just adjacent to the articular surface of the humeral head (Fig. 10-29). As the bone of the tuberosity is more cancellous, we typically use standard 4.5 or 5.5 triple-loaded rotator cuff anchors for this technique. Once the anchor is seated, the sutures are all taken outside of the cannula using a switching stick. The working

cannula is then reinserted into the joint. While visualizing from the ASP, the cannula is carefully backed up just outside the capsule along the infraspinatus. The cannula is then redirected more laterally toward the infraspinatus tendon. A penetrating tissue grasper pierces the infraspinatus tendon laterally, bringing it intra-articularly; the first limb of the inferiormost suture is grasped and retrieved out of the cannula. The penetrating grasper is advanced through the tendon again approximately 3 to 4 mm away and more medially from the first pass, this time grasping the partner suture of the same color, retrieving it out of the cannula as well, creating a mattress configuration. The cannula is removed and

FIGURE 10-29.  Illustration demonstrating a first anchor being inserted in the inferior aspect of the HS lesion just off the articular surface.

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142 SCOI Shoulder Arthroscopy

FIGURE 10-30. Illustration demonstrating a penetrating grasper via an extra-articular cannula passed through the infraspinatus tendon–capsule laterally, with the previously passed sutures stored in suture savers.

the two limbs of the suture are stored in a suture saver (Fig. 1­ 0-30). The process is repeated, moving more superiorly for each set of sutures until all suture pairs have been passed in a similar mattress fashion. Smaller lesions will typically require a ­ single ­ triple-loaded anchor, while larger ­lesions may ­require two ­anchors (Fig. 10-31). Limitation of ROM is the primary concern after the remplissage procedure, and to prevent postoperative stiffness, it is imperative to place the sutures laterally in the tendon. If instead the sutures are passed more

medially through the capsule, ROM may be limited significantly (Fig. 10-32). The sutures are all passed but not tied at this point, and are instead stored in suture savers posteriorly. Tying before completing the Bankart reconstruction can limit access inferiorly and compromise the repair. Attention is next directed to the anterior Bankart, which is completed as outlined above. Once the anterior reconstruction is complete, we return to the remplissage sutures and tie them to finalize our construct (Fig. 10-33). Knot tying can be performed either blindly over the capsule or while visualizing in the subacromial space, on the

FIGURE 10-31.  Illustration demonstrating a second suture anchor being inserted more superiorly, again just off the articular surface.

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Chapter 10

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Anterior Shoulder Instability 143

Hill-Sachs lesion

Capsule

Infraspinatus/ teres minor

Subscapularis

CORRECT

INCORRECT

basis of surgeon preference. To tie blindly, simply remove the posterior cannula and use a grasper through the cannula to retrieve the inferiormost suture pair with its suture saver. Advance the cannula down to the tendon level over the suture saver. Once the cannula is palpated to be just over the tendon, remove the saver and tie the knot using a locking-sliding knot with three alternating half-hitches reversing the post. ­Continue the same process until all the sutures have been tied. Alternatively, the surgeon can tie the sutures while visualizing from the subacromial space. Remove the

FIGURE 10-32.  Correct versus incorrect remplissage suture positions. Illustration reveals proper suture-passing position on the left side, with sutures all positioned through the infraspinatus tendon, whereas the image on the right side reveals an incorrect position, with sutures passed too far medially, which results in overtensioned posterior capsule that could significantly limit ROM and humeral rotation.

arthroscope in the glenohumeral joint from the ASP, and redirect the scope into the bursa. The suture savers will protect the sutures and can be easily located. Remove any hypertrophic bursal tissue with the shaver, and then place a cannula posteriorly. Retrieve the first set of sutures through the cannula from within the suture saver and tie them in a similar fashion as above, again repeating until all of the suture pairs have been tied.

Ant Bankart w Remplisage

Remplissage Alt

FIGURE 10-33.  Illustration demonstrating final repair, with

Bankart lesion repaired and final remplissage sutures being tied, with humeral head well centralized on the glenoid and HS lesion made extracapsular by the remplissage.

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144 SCOI Shoulder Arthroscopy

c POSTOPERATIVE REHABILITATION

8. Pagnani MJ, Warren RF. Stabilizers of the glenohumeral joint. J Shoulder Elbow Surg 1994;3:173–190.

Following surgery, patients are immobilized in a neutral ­rotation sling for 4 weeks. They start immediate elbow, wrist, and hand exercises, and are allowed to add gentle pendulums after the initial postoperative visit at 1 week after surgery. Supervised physical therapy begins at 4 weeks when they discontinue the sling. The emphasis is then on restoration of ROM and scapular rhythm. Progressive strengthening begins after 3 months, and anticipated return to sports and activity is typically at 6 months when full ROM and strength have been restored.

9. Owens BD, Harrast JJ, Hurwitz SR, et al. Surgical trends in Bankart repair: an analysis of data from the American Board of Orthopaedic Surgery certification examination. Am J Sports Med 2011;39:1865–1869. 10. Ryu RK, Ryu JH. Arthroscopic revision Bankart repair: a preliminary evaluation. Orthopedics 2011;34:17. 11. Petrera M, Patella V, Patella S, et al. A meta-analysis of open versus arthroscopic Bankart repair using suture anchors. Knee Surg Sports Traumatol Arthrosc 2010;18:1742–1747. 12. Mahirog˘ulları M, Ozkan H, Akyüz M, et al. Comparison between the results of open and arthroscopic repair of isolated traumatic anterior instability of the shoulder. Acta Orthop Traumatol Turc 2010;44:180–185.

SUMMARY Anterior shoulder instability is a common problem, which requires careful investigation to fully appreciate. While the diagnosis can be easy to make, determining the ideal management can be challenging. With the current techniques and proper understanding of the pathoanatomy, excellent outcomes can be expected with arthroscopic repair in properly selected patients.

References 1. Hovelius L. Incidence of shoulder dislocation in Sweden. Clin Orthop Relat Res 1982;166:127–131. 2. Hovelius L, Augustini BG, Fredin H, et al. Primary anterior dislocation of the shoulder in young patients: a ten-year prospective study. J Bone Joint Surg Am 1996;78:1677–1684. 3. Hovelius L. Anterior dislocation of the shoulder in teenagers and young adults: five-year prognosis. J Bone Joint Surg Am 1987;69:393–399. 4. Arciero RA, Taylor DC, Snyder RJ, et al. Arthroscopic bioabsorbable tack stabilization of initial anterior shoulder dislocations: a preliminary report. Arthroscopy 1995;11:410–447. 5. Arciero RA, Wheeler JH, Ryan JB, et al. Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocation. Am J Sports Med 1994;22:589–594. 6. Bankart ASB. Recurrent or habitual dislocation of the shoulder joint. Br Med J 1923;2:1132–1133. 7. Speer KP, Deng X, Borrero S, et al. Biomechanical evaluation of a simulated Bankart lesion. J Bone Joint Surg Am 1994;76:1819–1826.

13. Wang C, Ghalambor N, Zarins B, et al. Arthroscopic versus open Bankart repair: analysis of patient subjective outcome and cost. Arthroscopy 2005;21:1219–1222. 14. Yamamoto N, Itoi E, Abe H, et al. Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: a new concept of glenoid track. J Shoulder Elbow Surg 2007;16:649–656. 15. Ozbaydar M, Elhassan B, Diller D, et al. Results of ar throscopic capsulolabral repair: Bankart lesion versus anterior labroligamentous periosteal sleeve avulsion lesion. Arthroscopy 2008;24:1277–1283. 16. Purchase RJ, Wolf EM, Hobgood ER, et al. Hill-sachs “remplissage”: an arthroscopic solution for the engaging hill-sachs lesion. Arthroscopy 2008;24:723–726. 17. Itoi E, Hatakeyama Y, Kido T, et al. A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. J Shoulder Elbow Surg 2003;12:413–415. 18. Itoi E, Hatakeyama Y, Sato T, et al. Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence: a randomized controlled trial. J Bone Joint Surg Am 2007;89:2124–2131. 19. Paterson WH, Throckmorton TW, Koester M, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. J Bone Joint Surg Am 2010;92:2924–2933. 20. Penna J, Deramo D, Nelson CO, et al. Determination of anterior labral repair stress during passive arm motion in a cadaveric model. Arthroscopy 2008;24:930–935. 21. Wang DW, Getelman MH. “Hospital corner repair” for shoulder instability. Arthroscopy 2010;26:1706–1709.

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11

Instability with Glenoid Bone Loss c INTRODUCTION In cases of shoulder instability with glenoid bone loss, recognizing the bone loss, accurately measuring that bone loss, and selecting the appropriate surgical procedure are all key factors in obtaining successful outcomes. These steps, however, can be difficult, and either missing or underestimating even moderate bone loss can significantly affect outcomes and recurrence rates. Surgical options for the treatment of shoulder instability with glenoid bone loss usually include the following: arthroscopic Bankart labral repair, open Bankart labral repair, open or arthroscopic reduction with internal fixation of large bony fragments, open (or arthroscopic) Latarjet (or Bristow) coracoid transfer, non-Latarjet glenoid reconstruction with graft, or, rarely, shoulder fusion. Each procedure has its strengths, limitations, and risks. Relative indications for each depend, to a large degree, on the surgeon’s comfort and skill level, experience, and individual patient factors (age, activity level, etc.). Glenoid bone loss is extremely common after shoulder dislocation, being present in at least 50% to 95% of cases  (1). If significant bone loss goes unnoticed, the results of arthroscopic labral repair will be compromised. In patients with greater than 25% glenoid bone loss, 67% to 75% of patients had recurrence in the studies by Burkhart and Boileau, respectively (2,3). The use of bone restoration through Latarjet/Bristow procedures has been shown to significantly improve recurrent instability rates in patients with greater than 25% bone loss; in some reports, the rates were as low as 5% (4). It should be noted, however, that as the Latarjet has become more popular, the incidence of complication and failure mechanisms has been elucidated. An overall complication rate of 25% has been reported after Latarjet (5), and significant recurrence rates can be expected owing

to technical errors (6). The development of arthroscopic Latarjet/Bristow/Bankart repair may decrease complication and technical errors eventually, but this is currently an extremely difficult procedure, and more research is necessary. For those surgeons who are not comfortable or experienced in performing a Latarjet, we recommend referral to a shoulder subspecialist.

c THE SIGNIFICANCE OF BONE LOSS The degree of glenoid bone loss is typically characterized into three categories, mild, moderate, and severe, on the basis of the amount or percentage of bone loss from the glenoid surface. There are several techniques for measuring bone loss, but the current standard and most commonly accepted involves measuring the loss of bone across the horizontal diameter of the glenoid: Mild bone loss: less than 15% Moderate bone loss: 15% to 25% Severe bone loss: greater than 25% It should be noted, however, that glenoid bone loss has been measured in two different ways throughout the literature: as a percentage of glenoid bone loss to the horizontal glenoid diameter (2) or as a percentage of glenoid bone loss to the total vertical glenoid length (7). To properly interpret the published literature, it is important to recognize this distinction. For example, when measuring the percentage of glenoid bone loss as it relates to total glenoid length, “severe bone loss” is characterized by greater than 21% bone loss, not 25% bone loss. Both biomechanical studies and clinical studies have found that bone loss measuring greater than 25% of the glenoid width has a significantly higher risk of recurrent

145

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instability and leads to significantly elevated glenohumeral contact pressures. Burkhart et al. noted a 67% recurrence rate following arthroscopic repair in patients with greater than 25% glenoid bone loss, and only a 4% recurrence rate in those patients without significant bone loss (3,8). Other authors have published similar results of high recurrence rates in patients with greater than 25% glenoid bone loss. Owing to the preponderance of biomechanical and clinical evidence supporting the need to properly evaluate the degree of significant glenoid bone loss, and adjust the surgical approach accordingly, we highly recommend that all shoulder surgeons carefully measure the degree of bone loss in all of their patients with instability.

c IMAGING OF BONE LOSS The standard four shoulder x-ray views are obtained in all cases: anterior-posterior (AP), scapular outlet, axillary lateral, and Zanca acromioclavicular joint. In some cases, West Point views are obtained in an attempt to characterize the anterior-inferior glenoid. In a standard clinical setting, however, West Point views are very difficult to obtain accurately, and have been shown to be inferior to computed tomography (CT) scans in measuring significant anterior-inferior glenoid bone loss (7). Three-dimensional (3D) CT scans have been shown to be more reliable and accurate than 2D scans (9,10), and therefore if there is a concern that the glenoid bone loss may be greater than 25%, or greater than 15% in a revision situation, a CT scan with 3D reconstruction is ordered. Some surgeons recommend the use of bilateral CT scans to facilitate the measurement of glenoid bone loss with respect to the contralateral normal side. We do not routinely order 3D CT scans of the contralateral shoulder as we prefer to avoid the cost and extra radiation to the patient and feel comfortable measuring bone loss from the injured side only, using the technique given below.

Technique for Assessing Bone Loss from 3D CT The CT scan is obtained with humeral subtraction, allowing a clear view of the isolated glenoid en face. We prefer to use a ratio method to quantify the percentage of glenoid bone loss from a CT scan (11). A “best-fit” circle is drawn to contain the inferior glenoid. Although not perfect, the inferior glenoid does resemble a circle (Fig. 11-1). A vertical line is then drawn from the most superior aspect of the glenoid to bisect the circle. This line corresponds to the normal glenoid height and usually originates just posterior to the base of the coracoid. A second line is drawn perpendicular to the vertical line and at the widest portion of the inferior glenoid, creating four equal quadrants. The radius of the circle is then measured and can be recorded as A. The distance from the center of the glenoid circle to the bone defect edge is then calculated and recorded as B, corresponding to the amount of bone still present between the midpoint and the defect. To calculate the percentage of bone loss, the following equation is used: Percent bone loss = (A − B) / (2 × A)

FIGURE 11-1.  Calculating glenoid bone loss: Using the “best-fit circle” technique from a 3D CT scan, the percentage of bone loss can be calculated. A circle is drawn over the inferior glenoid edge (red circle). A vertical line is then drawn down from the glenoid apex bisecting this circle (red line). Another line is then drawn perpendicular to the vertical line, measured in two components: (A) from the posterior glenoid to the vertical line (yellow line), and (B) from the vertical line to the bone defect edge (black line). Percent bone loss is calculated as (A − B) / (2A). For example, if A measures 12 mm and B measures 6 mm, the percent bone loss is 25% and a Latarjet would be performed: (12 − 6) / (2 × 12) = 6/24 = 0.25. Similarly, if the value of B is less than or equal to 50% of the value of A, there is a greater than 25% bone loss. There are several alternative ways of measuring glenoid bone loss, but we have found this technique to be most useful in our preoperative planning. Intraoperatively, measuring with a calibrated probe from the “bare area” at the central glenoid can also be used to estimate bone loss, as described by Burkhart (2). This technique is not as precise as the CT scan technique, and the bare area is not present in all shoulders, but it is an excellent way to obtain a simple estimate (Fig. 11-2A, B). It should be noted, however, that on occasion, there is an obvious indication for a bone block technique, that is, greater than 25% bone loss clearly seen on radiographs or failure of prior arthroscopic Bankart with known bone loss (Fig. 11-3). In these cases, a CT scan may not need to be obtained, as it will not change the procedure to be performed (Latarjet), saving the patient from potentially harmful radiation. Magnetic resonance imaging (MRI) with gadolinium arthrograms are also obtained. This imaging is essential in characterizing soft tissue damage and planning surgery. In addition to labral damage, MRI arthrogram can also help elucidate the degree of capsular redundancy, damage to the rotator cuff, and humeral avulsion (HAGL) lesions. As the technology improves, MRI is also becoming a more accurate way of evaluating glenoid bone loss.

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Instability with Glenoid Bone Loss 147

A

A B

FIGURE 11-2.  Intraoperative measurement of glenoid bone loss: With the arthroscope in the ASP, a graduated probe can be introduced through the PSP. A. The probe, marked every 5 mm, measures the distance from the bare area (an approximate of the glenoid center) to the posterior rim of labrum, 16 mm in this case, such that the assumed diameter is 32 mm. B. The probe is then used to measure the distance from the center of the bare area (red circle) to the edge of the anterior glenoid rim, 11 mm in this case. Therefore, there is 5 mm of bone loss anteriorly, or 16% bone loss from the 32-mm glenoid diameter. This patient was treated with an ALR.

c SURGICAL PLANNING As discussed above, the patient’s physical exam, history of prior surgery, and the degree of glenoid bone loss affect the preoperative discussion. Regarding the surgical procedure to be performed, we make as many decisions as possible prior to arthroscopy, and prior to consent for surgery. We believe that it is in everyone’s best interests to be nearly certain about which surgical procedures will be performed prior to undergoing anesthesia, and we have found that we can predict with a high degree of certainty which procedure is the “correct” one for the patient preoperatively. Although a degree of uncertainty is always present, we have found that a patient properly consented as to their condition and the surgical alternatives is much less apprehensive about surgery and will not be disappointed if a procedure they were hoping to avoid is performed. Our algorithm for planning surgical intervention on ­patients with glenoid bone loss is outlined here (Fig. 11-4). As always, the algorithm represents general recommendations based upon a combination of published literature and personal experience accumulated from over 110 years of cumulative practice. We have found that the vast majority of patients with anterior-inferior instability (approximately 98%)

B

FIGURE 11-3.  This patient’s AP (A) and axillary (B) radiographs clearly show significant attritional glenoid bone loss and anterior subluxation despite prior stabilization surgery. This patient has a clear indication for Latarjet, and CT scanning should not be necessary. can be successfully treated with either arthroscopic Bankart labral repair (bony or all soft tissue) or Latarjet, each with or without remplissage. All other techniques do not amount to more than 2% of cases (Table 11-1). The degree of bone loss must be carefully evaluated. Mild bone loss (25%) is managed with a Latarjet if it is attritional without bone to repair, but if there is a large bony fragment amenable to fixation, arthroscopy followed by open or arthroscopic internal fixation is performed. Failed Latarjet procedures require complex reconstructive procedures such as autologous iliac crest bone grafting (ICBG) (12) or fresh distal tibial allografting (13).

c ARTHROSCOPIC REPAIR OF BONY BANKART Indications The absolute indications for early surgery of a bony Bankart lesion include the following: • Glenoid fragment greater than 25% • Concomitant injury requiring surgery (rotator cuff tear, proximal humerus fracture) • Irreducible dislocation • Nonconcentric reduction or interposed tissue • Failed trial of rehabilitation • Inability to tolerate shoulder restrictions

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The relative indications for surgery include the following: • Competitive athletes: overhead throwers, contact sports • Age less than 20 • More than two shoulder dislocations The vast majority of bony Bankart lesions are amenable to arthroscopic repair. When the bone can be reapproximated surgically, it reliably heals to union, and shoulder stability can be maintained. When a bone fragment is encountered during surgery, we always attempt to incorporate it into the repair. B

c SPECIAL INSTRUMENTS

A

Bony fragments larger than 25% of the glenoid occasionally require more complex arthroscopic or open reduction internal fixation (ORIF) techniques. Surgical consent for ORIF must be obtained preoperatively. For these cases, thoughtful planning for arthroscopic and open technique will be very helpful. We recommend that the following instruments be available: a long, 6- to 8-inch, hip arthroscopy spinal needle, long K-wires that will pass through the spinal needle, extended-length cannulas (i.e., Linvatec Dry-Doc Cannula, 7.0 × 95 mm, Translucent Blue w/Black cap, Largo, FL), an open shoulder instrument set with retractors, and cannulated 4.0- to 4.5-mm screws. If an arthroscopic bridging technique is to be performed, a 70-degree arthroscope is helpful.

c STANDARD BONY BANKART REPAIR TECHNIQUE With the patient in the standard lateral decubitus position, standard arthroscopic portals are utilized (posterior [PSP], anterosuperior [ASP], and anterior mid-glenoid [AMGP]). The area of the defect is defined, and soft tissue is removed from the fracture site. An arthroscopic liberator blade is used to carefully mobilize the fragment. Unfortunately, in many cases the fragment may not have any functional articular cartilage, especially when the damage is chronic or when the fracture fragment is relatively small ( 50 years old? Yes

Total shoulder arthroplasty

No

Yes

Severe pain and disability? No

Glenoid damage > humeral damage? Yes

Glenoid resurfacing Failed

Yes

Moderate pain and disability?

No

No Mild pain and disability?

Hemiarthroplasty Failed

Yes Oral analgesics, activity modification, physical therapy, hyaluronic acid injections

No

Minimal or no pain

Non-op treatment, consider work-up for syrinx

FIGURE 14-1.  This algorithm represents our very basic decision-making process for the management of shoulder OA by surgeons comfortable with both

arthroscopic and open techniques. Prior to consideration of this algorithm, it is imperative that the surgeon and patient agree on the patient’s candidacy for surgery and the expectations thereof. Infection must be considered and ruled out. Once determined, this algorithm begins with evaluation of the joint space. If there is still joint space present and no loss of concentricity, arthroscopy is indicated for the additional symptomatic comorbidities present. The results of arthroscopy will be inversely related to the degree of arthritis. In patients with severe radiographic arthritis who are over 50 years, we feel that TSA is the best option. In patients under 50 years, the situation becomes more complex, and the degree of pain and disability affect treatment. Those patients with severe debilitation need to consider TSA for its superior pain relief and acceptably low rate of glenoid component loosening. In patients with moderate disability, partial resurfacing is considered. In the rare cases of very young patients with severe glenoid damage but well-maintained humeral cartilage, an arthroscopic glenoid biologic resurfacing is performed. More often, the patients with even moderate disability have humeral damage as well. Humeral hemiarthroplasty is considered for such patients, especially if they are unwilling or unable to comply with recommended modifications of postoperative activity. Combined glenoid reaming, that is, “ream-and-run,” is performed in these cases if there is observed glenoid deformity. For patients with only mild or minimal disability, a nonoperative approach is taken, considering anti-inflammatory modalities, physical therapy, HA injections, and rare workup for syrinx in those patients with severe damage but no pain.

Microfracture While cartilage lacks the vascularity necessary for primary healing, it has been well documented in the knee literature that blood cells and marrow elements accessed from the bone can remodel into a layer of fibrocartilage. The indications, contraindications, and technique of microfracture in the shoulder are the same as those for the knee. The ideal patient has preserved humeral and glenoid bone shape, without significant squaring of the humerus or glenoid erosion. They

have a focal, unipolar, well-marginated chondral lesion, less than 1 to 2 cm², and the patient is less than 50 years of age. Patients with diffuse cartilage damage, very large lesions greater than 2 cm2, “kissing” lesions of cartilage loss on adjacent humeral and glenoid surfaces, loss of normal bony contour, and damage secondary to rheumatoid arthritis are poor candidates for success and should not undergo microfracture. After identification of the lesion, an arthroscopic shaver is used to carefully debride the loose chondral fragments and

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TABLE 14-1  OA Arthroscopic Treatment CLINICAL FINDING

ARTHROSCOPIC PROCEDURE

ROM loss

Capsular release

Biceps pain, tear, unstable SLAP tear

Biceps tenodesis

AC joint OA

Mumford

Subacromial impingement

Subacromial decompression

Isolated contained chondral defect (humeral head of glenoid)

Microfracture

Isolated peripheral glenoid chondral loss, especially with paralabral cyst

Labral advancement

Loose bodies/chondral fragments

Removal/chondroplasty

Synovitis

Synovectomy

ligaments. Arthritic shoulders should not be surgically tightened and, therefore on occasion, labral advancement can be performed concomitantly with an arthroscopic capsular release.

A

When arthroscopically managing the OA shoulder, the procedure(s) ­performed depend on the pathology present. When arthroscopy is to be performed, the procedures selected are based on the clinical findings.

confirm its candidacy for microfracture. Curettes are used to remove damaged cartilage and establish a vertical wall of viable, stable cartilage surrounding the lesion. Creating this type of vertical wall can be difficult in the shoulder, especially on the humeral side. Shoulder rotation and careful adjustment of operating portals can be helpful to gain proper access. Arthroscopic awls are then used to create microfracture holes around the periphery and through the center of the lesion. The holes are placed 3 to 5 mm apart and at least 2 to 3 mm deep. More recently, new types of microfracture awls with smaller and deeper penetration have come to market from companies such as Arthrosurface, Inc. (Franklin, MA). Microfracture can be performed on either the glenoid (Fig. 14-2) or the humeral sides (Fig. 14-3). Postoperatively, patients are instructed to avoid any shear stress on the shoulder for 6 weeks, but they are encouraged to perform pendulum ROM activities. A shoulder continuous passive motion (CPM) machine is not utilized. Unrestricted weight training is allowed at approximately 12 weeks. Full activity may be resumed at 16 weeks.

Labral Advancement When the focal damaged cartilage is peripheral, adjacent to the labrum, labral advancement is performed (what we occasionally refer to as a “combover”) in order to both cover the exposed bone and stabilize the labrum. Exposed bone 5 to 7 mm from the glenoid edge can be covered fairly easily without undue tension or overtightening of the glenohumeral

B

C

FIGURE 14-2.  Microfracture of the glenoid, right shoulder. The anteriorinferior cartilage is irreparably damaged and delaminated (A). A careful debridement is performed to remove damaged cartilage and create vertical walls of healthy cartilage (B). Microfracture picks can then be used to penetrate the subchondral bone (C).

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Glenohumeral Osteoarthritis 199

A

B

C

D

FIGURE 14-3.  Microfracture of the humeral head, right shoulder. The loose fragmented cartilage is debrided out (A), the subchondral bone is exposed just below the calcified layer (B), and microfracture awls are carefully positioned (C) to provide holes every 3 to 4 mm throughout the defect (D).

Three standard arthroscopy portals are utilized: posterior, anterosuperior, and anterior mid-glenoid. The Wilmington portal or the “7 o’clock” portal is often helpful for accessing posterior glenoid lesions. (The Wilmington portal is generally located 1 cm lateral to the posterolateral acromial corner, and the 7 o’clock portal approximately 4 cm lateral to this corner.) A debridement of the bone and labrum is performed to remove the loose, dysfunctional tissue. A small bonecutting shaver or rasp or both are used to create a bleeding cortical surface on the exposed bone. Degenerative, sclerotic bone will be less likely to heal to the labrum. A grasper is utilized to determine the mobility of the labrum, and a liberator elevator is used as needed to free up its attachment if more coverage is needed. Suture anchors are then placed, inferior to superior, sequentially along the edge of the cartilage, on the face of the glenoid. These anchors are usually single-loaded with #2 or #1 high-strength suture. Double-loaded anchors are helpful for fixation at the 5 or 7 o’clock “corner” of the inferior glenoid, where stitches can be passed at 70- to 90-degree angles to each other, capturing tissue as it curves around the glenoid at the sharpest angle. Simple stitches are used as a standard, with vertical ­mattress stitches as an option for eversion of the labrum

over a larger area of exposed bone (Fig. 14-4). The technique for a labral mattress suture is a basic two-step process using the standard shuttling technique (as described in the chapters on instability: ch.10,11,12,13, and 16.); one limb of the suture is passed all the way around the labrum, and then the second limb is passed through a very small 2-mm bite of central labrum. This second pass ensures that the stabilized central labrum will be everted onto the bone, covering more area, and will not be inverted/rolled under itself, as tends to happen with large labral simple stitches (Fig. 14-5A–D).

c DIFFUSE CHONDRAL DAMAGE AND STIFFNESS For patients with more diffuse chondral damage and stiffness, an arthroscopic capsular release with glenohumeral debridement is performed. Ideal patients are those with fairly well-maintained joint spaces, minimal

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Before

FIGURE 14-4. Labral

advancement. After preparation of the glenoid bone, small suture anchors are placed at the chondral junction and used to advance the labrum over the exposed bone. Mattress sutures can be helpful in everting the labrum over the bone.

osteophyte formation, and a concentric, well-reduced glenohumeral joint. The procedure is performed in the standard lateral position, using the three standard arthroscopic portals: posterior, anterior-superior, and anterior mid-glenoid. After a complete diagnostic arthroscopy, including the subacromial space, all loose fragments of cartilage on the articular surfaces and labrum are debrided with an arthroscopic shaver. The stability of the labrum is carefully probed, and despite a very high incidence of labral detachment in these patients, labral repair is almost never performed as it is usually contraindicated. The biceps anchor is also carefully evaluated, as is the proximal biceps tendon itself. If either the anchor or biceps tendon is damaged, biceps tenodesis or tenotomy is performed. All loose bodies are removed. It is very important to closely evaluate the subscapularis recess from the anteriorsuperior viewing portal, as well as to closely evaluate the axillary pouch from the posterior viewing portal, utilizing a 70-degree arthroscope if necessary. Loose bodies can cause severe disability, and their removal can provide significant symptomatic improvement (Fig. 14-6A, B). Osteophytes can often be removed arthroscopically, but special care must be taken to avoid damaging the axillary nerve. Again, a 70-degree arthroscope can be very useful, as can a low anterior (5 o’clock) or a low posterior (7 o’clock) portal. If care is taken to avoid penetration of the capsule

A

B

C

D

FIGURE 14-5.  Labral advancement example: Right shoulder, anterosuperior viewing portal demonstrates a peripheral area of chondral loss and labral detachment posteriorly (A). The labrum is appropriately mobile (B). After passage of one suture limb around the entire labrum, a mattress stitch can be created by passing the second suture limb through the labral edge, everting the tissue (C), covering the cartilage defect (D). (c) 2015 Wolters Kluwer. All Rights Reserved.

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Glenohumeral Osteoarthritis 201

and the patients are encouraged to do a home exercise program 7 days a week. Return to activity is as tolerated.

c DIFFUSE ISOLATED GLENOID DAMAGE Glenoid Resurfacing

A

B

FIGURE 14-6.  This patient developed severely symptomatic loose bodies after multiple instability events and arthroscopic anterior stabilization. Referred for shoulder arthroplasty, this 23-year-old had multiple loose bodies (A) and achieved significant functional gains after arthroscopic removal (B). while removing the humeral head osteophyte, the axillary nerve should be safe. Lastly, a pancapsular release is performed. With the arthroscope in the posterior portal, the rotator interval, anterior capsule, and anterior-inferior capsule are released just adjacent to the labrum. With the arthroscope in the anteriorsuperior portal, the posterior, posterior-inferior, and inferior capsule can be released. The arm can be taken out of traction and examined for ROM. Subsequent bursal and/or biceps work can then be performed. Postoperatively, a sling is worn for comfort only, and the patient is encouraged to move the shoulder as much as possible. Physical therapy begins by 48 hours postoperatively,

This procedure has limited indications at the Southern California Orthopedic Institute (SCOI). We developed the technique in 2005 as a potential alternative for young patients with advanced glenohumeral arthritis and chondrolysis. At the time, the use of intra-articular Marcaine pain pumps was associated with many such cases, increasing the need for alternatives to arthroplasty. While early results were quite promising, and a second-look biopsy specimen showed bone attachment, chondrocytes, and organized fibrocartilage bundling, the midterm results were disappointing. At 3 years postoperatively, 40% of the patients had gone on to require arthroplasty. As a result, we significantly narrowed the indications for arthroscopic limited resurfacing: 1. Patients less than 50 years of age, with moderate pain, severe glenoid chondral loss, and fairly well-maintained humeral cartilage. For example, patients with glenoid fractures and posttraumatic arthrosis of the glenoid. 2. Young patients with moderate pain status post hemiarthroplasty. Patients with severe pain should be treated with a TSA, whereas patients with mild pain are treated conservatively. Very young patients, less than 40 years of age, with chondrolysis, performed concomitantly with open humeral resurfacing. We currently use the same acellular human dermal graft tissue used in rotator cuff augmentation. The procedure is set up as a traditional and standard shoulder arthroscopy. The patient is administered general anesthesia and prophylactic intravenous antibiotics, and placed in the lateral decubitus position. An axillary roll is placed, and the thorax is stabilized with a beanbag. The arm is reexamined for passive ROM and subsequently prepped, draped, and placed in standard glenohumeral arthroscopy position: 60 to 70 degrees of abduction, 15 degrees of forward flexion, and 10 pounds of traction. Appropriate bony landmarks are marked with a sterile marking pen, and the glenohumeral joint is entered via a posterior arthroscopy portal placed approximately 2 cm distal and 1 cm medial to the posterolateral corner of the acromion. Arthritic joints are typically tighter, and care should be exercised when introducing the arthroscopic trocar into the joint. Once inside the glenohumeral joint, an anterior ­mid-glenoid portal (AMGP) is created approximately 3 cm anterior and 2 cm medial to the anterolateral acromial corner. A translucent cannula is placed, and a complete glenohumeral arthroscopic examination is performed from both the anterior and the posterior portals. The status of the articular surfaces is closely evaluated, as is the glenoid ­subchondral bone and labrum. In most cases of primary glenohumeral arthritis, the labral tissue will be well preserved or even robust (Fig. 14-7). After glenohumeral evaluation, an anterosuperior portal (ASP) is created in the superior rotator interval using an

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gently debrided back. We do not currently attempt to remove humeral or glenoid osteophytes in their entirety. Osteophytic bone is removed to maximize visualization and to create a generally smooth humeral surface. Using a motorized shaver or gentle burr, the glenoid is debrided down to bleeding subchondral bone (Fig. 14-8). All residual cartilage is removed, but minimal glenoid bone is removed to maximize bone stock for potential future procedures. In some cases where a biconcave glenoid has developed, the glenoid can be reshaped to restore more ­anatomical concavity and version.

Measurement of the Glenoid

FIGURE 14-7.  A severely damaged glenoid (G) with chondrolysis after pain pump usage.

outside-in technique: A spinal needle first establishes the correct position, located approximately 1 cm anterior to the anterolateral acromial corner. The arthroscope is then moved to this position for the remainder of the case. A second, clear cannula (8 to 8.5 mm in diameter) is placed in the posterosuperior portal (PSP).

Glenoidplasty After arthroscopic examination and creation of all three portals, a debridement of the joint is performed. The humeral head can be debrided of loose cartilage, and osteophytes are

FIGURE 14-8.  Glenoid resurfacing: The glenoid is debrided of damaged cartilage with a shaver, working from both anterior and posterior portals.

After debridement and glenoidplasty, the dimensions of the glenoid are measured in anterior-to-posterior and superiorto-inferior directions. For accurate measurement, we use a knotted suture as a measuring device. A size 0 suture is prepared preoperatively with five single knots, spaced exactly 1 cm apart (Fig. 14-9). The end knot is used as a reference point and is held at the 12 o’clock position on the glenoid bone with an arthroscopic grasper. A knot pusher is used to extend the suture across the glenoid down at the 6 o’clock position so that the length of the glenoid is equal to the distance from the end knot to the knot pusher. The glenoid length is recorded, and then the identical technique is used to measure and record the glenoid width from the 3 to 9 o’clock position. On the back table, the graft is prepared. It is hydrated as necessary and then cut with suture scissors into an oval that matches the dimensions of the glenoid.

Glenoid Microfracture While the graft is being cut to size and prepared, the ­glenoid is microfractured with the arthroscopic awls commonly used for microfracture in the knee joint (Fig. 14-10). The goal of the microfracture is to create conduits for stem cells within the blood to reach and populate the graft. The holes

FIGURE 14-9.  Measuring suture: Using a #0 braided suture, knots are carefully placed every centimeter. This device is used for accurate measurement of the glenoid from within the shoulder.

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Glenohumeral Osteoarthritis 203

side of the graft—this is the side that will face the humeral head. The rougher side of the graft is the reticular side and will be placed down on the glenoid. Six STIK sutures are placed around the graft, at the 1, 3, 5, 7, 9, and 11 o’clock positions. We use high-strength #2 braided sutures for these STIK sutures.

Suture Passage Through the Labrum

FIGURE 14-10.  Glenoid

resurfacing: Microfracture is performed after shaping and debridement of the glenoid.

are placed throughout the glenoid, approximately 3 to 5 mm apart from each other.

Graft Preparation As stated above, the graft is cut to size in an oval/pear shape on the back table. To complete its preparation for implantation, a large, straight Keith needle is used to place six ­knotted short-tailed interference knot (STIK) sutures through the graft around its circumference, each 3 mm from the edge. A STIK suture is created by tying a knot with 4 to 6 throws on the end of a #2 braided suture. The tail is cut to approximately 5 mm (Fig. 14-11). In this case, the STIK knots serve to hold the sutures in the graft, preventing slippage. The Keith needle is used to penetrate the graft and pull the suture through such that the interference knots lie on the top/basement membrane

FIGURE 14-11.  “Short-tailed interference knot,” aka “STIK” knots.

Four of the six STIK sutures (all three anterior STIKs as well as the posteroinferior STIK) are then sequentially passed through the labrum with the following carefully ordered technique. An assistant must carefully hold the graft outside the PSP, maintaining consistent orientation to avoid twisting the graft and tangling the sutures. Using a curved Spectrum suture hook (ConMed, Inc., Largo, FL) loaded with a Suture Shuttle (ConMed, Inc., Largo, FL) via the PSP, the posteroinferior labrum is penetrated, and a large amount of Shuttle is fed into the joint (Fig. 14-12). The stitcher is removed and a grasper retrieves the Shuttle end back out of the PSP. From the graft, the posteroinferior STIK is then loaded into the Shuttle eyelet (Fig. 14-13). The free end of the Shuttle is then gently pulled, bringing the suture down the cannula, through the labrum, and back out of the PSP. Thus, the first suture (posteroinferior, 7 o’clock on a right shoulder) is passed from the graft through the labrum. The two ends of this suture are held together against the inferior edge of the cannula to prevent entanglement. Following passage of the posteroinferior (7 o’clock) suture, the anteroinferior (5 o’clock) suture is passed. Stitching now from the AMGP, a suture Shuttle is passed through the labrum

FIGURE 14-12.  The posterior-inferior suture is placed using a shuttling

device.

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204 SCOI Shoulder Arthroscopy

FIGURE 14-13.  A Shuttle is passed several inches into the joint such that it can be retrieved out of the posterior portal after the stitcher is removed.

FIGURE 14-14.  The second stitch is passed anteroinferiorly through the

and brought out of the PSP with a grasper. As the suture from the 7 o’clock stitch is also in the PSP cannula, there is a risk of entanglement if the grasper or Shuttle should wind around this other suture. To avoid crossing sutures, all previously passed sutures in the PSP are firmly held in the inferior aspect of the PSP cannula. The grasper is then carefully placed into the joint via the opposite, superior, aspect of the PSP cannula to retrieve each Shuttle. In this way, each subsequent Shuttle will have a parallel path to and from the labrum. Understanding this technique is essential to avoid tangling the sutures. After retrieving the anteroinferior Shuttle out of the PSP, the corresponding STIK suture from the graft (anteroinferior, 5 o’clock) is loaded in the Shuttle eyelet (Fig. 14-14). The suture is then pulled across the joint, through the labrum, and out of the AMGP. Using identical technique, the other two anterior sutures on the graft are then passed sequentially through the 3 and 1 o’clock areas of the anterior labrum, taking care to hold previously passed sutures in the inferior aspect of the PSP cannula, and to pass the graspers and Shuttles through the superior aspect of the PSP cannula. In this way, four of the six sutures in the graft have been passed into the joint and across the labrum. The posteroinferior suture is in the PSP, whereas all three anterior sutures pass into the joint via the PSP, cross the anterior labrum, and exit the joint via the AMGP.

the graft is carefully pushed through the posterior cannula into the joint (Fig. 14-15). Slack from the posteroinferior 7 o’clock suture is also gently pulled out via the PSP as the graft approaches the glenoid. Once inside the joint, the graft will expand and be held to the labrum via four points of fixation: the STIK knots at 7, 5,

AMGP, and carefully shuttled out of the posterior portal, staying superior to the other stitch in the cannula.

Graft Insertion The next step is to “push-pull” the graft into the joint via the PSP. Taking care not to twist the sutures, the graft is folded in half and held with a grasper. The three anterior sutures are gently pulled in unison from the anterior cannula, and

FIGURE 14-15.  After four of the six STIK sutures have been passed, the graft is ready for insertion.

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Chapter 14

FIGURE 14-18.  Six

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Glenohumeral Osteoarthritis 205

circumferential sutures secure the graft over the

glenoid.

FIGURE 14-16.  The

graft is push-pulled down the posterior cannula, sutures are gently pulled to unfold it over the glenoid, and tying begins.

3, and 1 o’clock positions. Each STIK knot is then sequentially grasped, pulled out of the joint, and tied with a slidinglocking arthroscopic knot (Fig. 14-16). Four of the six points of fixation have now been established. The posterior 9 o’clock suture is then addressed. Using a penetrating grasper via the PSP, the labrum is pierced at the 9 o’clock position; the suture is grasped from beneath the graft, carried through the labrum, and out of the PSP (Fig. 14-17). Its STIK knot end is then retrieved, and the suture is tied.

The final suture to be passed and tied is the posterosuperior 11 o’clock STIK. A penetrating grasper can occasionally be used, but a curved suture hook is usually most effective. The free end of the suture is first brought out of the AMGP with a crochet hook, the labrum is pierced with the suture hook via the PSP, and a Suture Shuttle is used to carry the suture back through the labrum. Its STIK knot is then retrieved and the final knot is tied (Fig. 14-18). The graft is now fixed at six points around the ­glenoid labrum. Tension is kept to a minimum to prevent the graft from “trampolining” away from the glenoid surface (Fig.  14-19). When the arm is taken out of traction, the humeral head will help stabilize the graft and provide comp­ ression against the glenoid.

FIGURE 14-17.  The 9 o’clock stitch is passed through the labrum with a penetrating bird-beak-type grasper.

FIGURE 14-19. The ­human dermal matrix.

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glenoid has been resurfaced with an acellular

206 SCOI Shoulder Arthroscopy

Postoperatively, each patient is placed in a neutral sling for 3 weeks. Hand, wrist, and elbow exercises are begun immediately. Passive glenohumeral motion is delayed for 3 weeks to allow early graft incorporation. Active motion is allowed after 6 weeks.

Glenoid Resurfacing

c OTHER TECHNIQUES Autologous Cartilage Implantation Patients with large lesions not suitable for other techniques, and who have failed conservative management, may benefit from autologous cartilage implantation (ACI). However, there is very limited research on the topic. The procedure is a two-stage procedure, and currently requires a deltopectoral incision with humeral dislocation for implantation. The development of matrix-induced autologous chondrocyte implantation (MACI), whereby the chondrocytes are grown directly onto a collagen membrane, may allow relatively larger areas of damaged cartilage to be treated arthroscopically.

Osteochondral Autograft/Allograft Implantation Similar to ACI, there is very little published literature for osteochondral implantation in the glenohumeral joint. Osteochondral autograft transfer (OAT) has significant morbidity, and should be limited to lesions less than 1.5 cm². Fresh osteoarticular allografts are promising in terms of their ability to replace damaged cartilage with healthy cartilage. There is no donor site morbidity, but grafts should ideally be transplanted within 21 days and no later than 28 days following graft harvest. This time frame presents a difficult scheduling problem for surgeons and patients alike, as the surgeons are usually notified of graft availability with only days to spare before the graft viability expires. Currently, these techniques are not part of the standard treatment algorithm for management of OA in the glenohumeral joint.

FIGURE 14-20.  When

removing a loose glenoid polyethylene from a painful TSA, the pegs (P) are removed first with a small osteotome (O).

For removal, we use a ¼-inch osteotome in a technique similar to that described by O’Driscoll et al. The osteotome is used alternatively through different portals to first detach the pegs or keel from the back of the glenoid (Fig. 14-20), after which they can be removed through an extended AMGP. Working from superior to inferior, the glenoid face is then cut into pieces with the osteotome, and each piece is removed sequentially (Fig. 14-21). Burrs and biters are ineffective against the strong glenoid polyethylene. After removal, the bone is debrided, but grafting is not performed if there is any suspicion of infection. We have not seen any improvement in outcomes with or without glenoid bone Loose Glenoid grafting.

Excision of Loose Glenoid after Arthroplasty Arthroscopy can have a useful role in the management of the painful TSA as well. Subtle infection with P. acnes is very difficult to diagnose without good biopsy specimens to culture. We hold cultures for 21 days when P. acnes infection is suspected. Arthroscopy can also be used to diagnose and/ or excise a loose glenoid component without violating the subscapularis through a large deltopectoral approach. The procedure is performed in the standard lateral position, with standard PSP, ASP, and AMGP. The arthroscope is used in both the PSP and the ASP. A synovectomy is performed and multiple tissue cultures are obtained. A loose glenoid is easy to diagnose arthroscopically with a probe.

FIGURE 14-21.  After the removal of the pegs, the remaining glenoid is cut into pieces with a thin osteotome and a mallet. These fragments of glenoid (G) can then be easily removed through the AMGP or posterior portal.

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Chapter 14

Suggested Readings Cole BJ, Yanke A, Provencher MT. Nonarthroplasty alternatives for the treatment of glenohumeral arthritis. J Shoulder Elbow Surg 2007;16(Suppl):231S–240S.

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Glenohumeral Osteoarthritis 207

O’Driscoll SW, Petrie RS, Torchia ME. Arthroscopic removal of the glenoid component for failed total shoulder arthroplasty: a ­report of five cases. J Bone Joint Surg Am 2005;87(4): 858–863.

Savoie FH, Brislin KJ, Argo D. Arthroscopic glenoid resurfacing as Millett PJ, Huffard BH, Horan MP, et al. Outcomes of full-­ a surgical treatment for glenohumeral arthritis in the young patient: thickness articular cartilage injuries of the shoulder treated with midterm results. Arthroscopy 2009;25:864–871. micro­fracture. Arthroscopy 2009;25:856–863. Scalise JJ, Miniaci A, Iannotti JP. Resurfacing arthroplasty of the Nakagawa Y, Hyakuna K, Otari S, et al. Epidemiologic study of humerus: indications, surgical technique, and clinical results. Tech glenohumeral osteoarthritis with plain radiography. J Shoulder Shoulder Elbow Surg 2007;8:152–160. ­Elbow Surg 1999;8(6):580–584. Sperling JW, Cofield RH, Rowland CM. Near hemi-arthroplasty Noël E, Hardy P, Hagena FW, et al. Efficacy and safety of Hylan G-F and near total shoulder arthroplasty in patients 50 years old or less. 20 in shoulder osteoarthritis with an intact rotator cuff: open-label J Bone Joint Surg Am 1998;80:464–473. prospective multicenter study. Joint Bone Spine 2009;76:670–673.

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15

Subacromial Impingement and Arthroscopic Subacromial Decompression c INTRODUCTION The anatomy of the shoulder joint, with the rotator cuff ­tendons interposed between the acromion and the humeral head, predisposes the supraspinatus tendon to mechanical injury from the overlying structures such as the acromion, the coracoacromial ligament, and the acromioclavicular joint during movement of the shoulder joint into positions of forward flexion and rotation. Subacromial impingement was recognized as a source of possible shoulder pain by many early authors, and some of these authors proposed complete acromionectomy or lateral acromionectomy for relief of these symptoms. However, it was Dr. Charles Neer (1) who published a classic article in 1972 and popularized the term impingement syndrome. Dr. Neer noted in cadaver dissections that mechanical impingement could occur owing to a spur on the anterior acromion and lead to rotator cuff tears. He emphasized that it was the anterior portion of the acromion that caused the impingement, and that a partial resection of the anterior acromion could give good clinical results in patients with impingement syndrome. Dr. Neer’s article had a profound impact on treatment for rotator cuff disease in the shoulder, and open acromioplasty became the preferred treatment for rotator cuff disease, often in combination with rotator cuff repair. As arthroscopic ­surgery was subsequently perfected, a transition occurred to performing these procedures arthroscopically. Multiple s­tudies have shown results of arthroscopic acromioplasty to be equal to or better than open acromioplasty. In 1986, Bigliani et al. (2) presented results of a study of 140 shoulders from 71 cadavers. They identified three types of acromial shapes: Type I (flat), Type II (curved), and Type III (hooked) (Fig. 15-1). They noted that 73% of patients

Flat

Curved

Hooked

FIGURE 15-1. Bigliani

and Morrison identified three acromial types: Type I, flat (top); Type II, curved (center); and Type III, hooked (bottom) (see text for details).

with rotator cuff tears had a Type III acromion, 24% had a Type II acromion, and only 3% had a Type I acromion. This supported the concept of anterior acromial impingement as a cause of rotator cuff tears and helped to guide surgeons in the appropriate amount of resection for the anterior acromion, 209

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210 SCOI Shoulder Arthroscopy

with the goal of converting a Type II or III acromion into a Type I (flat) acromion. Subsequently, Wuh and Snyder (3) emphasized the importance of also determining the thickness of the acromion preoperatively when planning a subacromial decompression. They classified the acromial shape further into A, B, or C thickness. Measuring at the junction of the middle and distal portion of the acromion on an arch view x-ray, thicknesses of less than 8 mm were considered to be Type A, 8 to 12 mm to be Type B, and greater than 12 mm to be Type C. They felt that determining acromial thickness preoperatively was necessary to prevent over- or underresection of the acromion at the time of surgery. Recently, investigators have called into question the importance of performing subacromial decompression concomitantly with rotator cuff repair (4,5). While we believe that there are certainly cases of rotator cuff tearing that can occur in the absence of significant mechanical impingement, we also believe that many patients with rotator cuff pathology do have significant subacromial pathology, which is evidenced by the findings at the time of surgery. We continue to believe that these patients will do better with subacromial decompression, and subacromial decompression may also prevent potential rubbing of the sutures from rotator cuff fixation underneath the acromion postoperatively. We hypothesize that the marrow elements exposed by the subacromial decompression may also aid in the healing of the rotator cuff repair. Therefore, it is still important to employ subacromial decompression in patients with clinical and operative findings of impingement. In this chapter, we will discuss the diagnosis of impingement syndrome, the indications for arthroscopic subacromial decompression (ASD), and a reproducible technique for performing subacromial decompression to ensure maximum decompression of the supraspinatus tendon and to minimize potential risks and complications.

c CLINICAL HISTORY AND EVALUATION Clinical Presentation and Symptoms In general, patients with impingement syndrome relate a gradual onset of shoulder symptoms. They commonly complain of pain with activities performed at or above shoulder level. As the patients become more symptomatic, they also often report difficulty sleeping on the affected shoulder. The pain is generally over the anterior and lateral aspect of the shoulder. They may complain of varying degrees of weakness. Patients may also present with a more acute, traumatic history of falling on the shoulder, or of injury when lifting a heavy weight. Such a history increases the likelihood of a rotator cuff tear. In evaluating the shoulder for impingement syndrome, it is important to adequately visualize the entire posterior aspect of the shoulder, including the scapula. Checking the range of motion is critical. Many patients with early adhesive capsulitis may be confused with patients having an impingement syndrome. Both of these groups of patients will have pain with overhead activities. However, a hallmark finding in adhesive capsulitis is a loss of external rotation of the affected shoulder with the arm at the side when compared with the nonaffected shoulder. The patient may also exhibit a significant loss of internal rotation of the shoulder

FIGURE 15-2.  Neer’s classic test for impingement is pain with passive forward flexion of the shoulder beyond 90 degrees.

behind the back as the adhesive capsulitis progresses. Such findings would be unlikely with an impingement syndrome alone. In checking rotation, it is important to have the patient lie in a supine position to stabilize the scapula and to give a true measurement of actual glenohumeral motion. Loss of glenohumeral motion may be obscured when the patient is in a standing position, as the patient will use extra scapulothoracic motion to compensate for glenohumeral motion. Examination frequently reveals tenderness over the anterolateral shoulder in the area of impingement. Neer’s classic impingement sign is pain with passive forward ­flexion of the shoulder above 90 degrees (Fig. 15-2). Hawkins described an additional test that involves passive forward flexion of the shoulder to 90 degrees followed by internal rotation of the arm. Pain with this maneuver indicates an impingement syndrome (Fig. 15-3). Jobe delineated a further modification of the test in which the arm is ­forward flexed 90 degrees and resisted pronation causes pain, suggestive of impingement (Fig. 15-4). Patients may have a variable amount of weakness, particularly to supraspinatus resistance with the arm in a forward-flexed position and to external rotation with the arm at the side. Significant weakness and pain with these tests may indicate the presence of a rotator cuff tear, although weakness may also occur secondary to pain with impingement without an actual tear. Additional tests may also be helpful to determine the presence of any associated pathology such as acromioclavicular arthritis, biceps tendonitis, subscapularis tendon abnormalities, or instability. Injection of local anesthetic into the subacromial space, with or without corticosteroid, can be very helpful in making the diagnosis of impingement; this has been termed an impingement test. We generally inject the subacromial bursa from anteriorly with 1 ml of corticosteroid, 3 ml of 0.25% Marcaine, and 3 ml of 1% Xylocaine. Ultrasonic guidance may be helpful when performing this injection to confirm

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Subacromial Impingement and Arthroscopic Subacromial Decompression 211

rather than mechanical disruption of the rotator cuff. ­Failure to respond to the initial subacromial injection of anesthetic calls into question the diagnosis of impingement, and may make an intra-articular source of pain such as adhesive ­capsulitis a more likely diagnosis.

Imaging Studies

the appropriate placement of the anesthetic into the bursa. The examiner then repeats the impingement tests following injection of the anesthetic. If the patient has significant improvement in pain and improved ability to forward-­elevate the arm after the injection, this supports the diagnosis of an impingement problem. Strength should also be reevaluated, and if the strength is normal after the injection, this indicates that the previously noted weakness was coming from pain

Appropriate imaging studies are critical for accurately ­diagnosing and treating impingement problems. We obtain four x-ray views of the shoulder in all of these patients. These consist of a true anterior-posterior (AP) view of the shoulder and glenohumeral joint, a view of the acromioclavicular joint, with the x-ray angled in a cephalad ­direction, an axillary view of the shoulder, and an arch view of the shoulder. It is important to determine that there is no ­significant glenohumeral joint arthritis that may be ­contributing to loss of motion and that may masquerade as impingement. X-rays may also reveal the presence of calcification in the rotator cuff tendon, which can contribute to ­symptoms and be the patient’s primary problem. It is important to ­evaluate the acromioclavicular joint for associated ­arthritis, and p­ articularly for inferiorly directed spurs from the acromioclavicular joint, which may be contributing to the impingement. On the axial view, it is also imperative to look for evidence of an os acromionale (Fig. 15-5). This will be essential when planning surgical intervention, as ­discussed later in this chapter. The arch view is important in determining whether mechanical impingement is present, and also in determining preoperatively how much bone resection will be performed on the anterior acromion. The arch view is a modified scapular Y view, with approximately a 30-degree caudal tilting of the x-ray tube (Fig. 15-6). On the arch view, the acromion is

FIGURE 15-4.  Jobe’s test for impingement involves forward flexion of

FIGURE 15-5.  The x-ray axillary view should be scrutinized to reveal a

FIGURE 15-3.  A positive Hawkin’s test elicits pain when the shoulder is forward flexed 90 degrees and then internally rotated.

the arm to 90 degrees and resisted pronation, which causes pain.

possible os acromionale (arrow).

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212 SCOI Shoulder Arthroscopy

A

FIGURE 15-6.  To obtain the modified scapular Y view (arch view), the x-ray tube is aligned with the scapular spine and angled 30 degrees caudally. classified as Type I, II, or III and as an A, B, or C thickness. Patients with a large Type III arch may be at a higher risk for impingement and rotator cuff tearing and will require more bone resection if subacromial decompression is performed. We also note the actual morphology of the acromial shape, with some patients having a very curved acromion from posterior to anterior and other patients having a relatively flat acromion with a large anterior spur (Fig. 15-7A, B). Each of these patients requires a different amount of arthroscopic bone resection. In most of these patients, we perform magnetic resonance imaging (MRI) to better determine the status of the rotator cuff tendon and also to ensure that there is no other associated pathology. A characteristic finding in patients with impingement is a significant amount of subacromial fluid accompanied by some bursal irregularity of the superior surface of the supraspinatus tendon (Fig. 15-8).

Conservative Treatment of Impingement Syndrome As Neer emphasized in his original article on impingement, the majority of patients with impingement ­syndrome will do well without the need for surgery. Prior to ­considering surgical intervention, we will try a prolonged course of conservative treatment for patients who do not have a significant rotator cuff tear. The patient begins a strengthening program for the rotator cuff using a ­Theraband (Fig. 15-9), and is also instructed in a stretching program to prevent or treat any associated adhesive capsulitis. Anti-inflammatory medicines may be helpful as are ice, rest, and activity modification, particularly avoiding aggravating activities performed at or above shoulder level. We will generally administer a corticosteroid injection into the subacromial space. Although the

B

FIGURE 15-7.  X-rays may reveal a thin, curved acromion (A) or a thicker, flat acromion with an anterior hook (B).

efficacy of such an injection is controversial, many patients will respond well, with significant and rapid improvement in symptoms. As noted above, injecting anesthetic at the same time can also confirm the diagnosis of impingement and give an idea of the prognosis for surgical intervention if symptoms persist. In our experience, patients who do not have some initial improvement from the anesthetic injection into the subacromial bursa are unlikely to be improved by subacromial decompression, while patients who have an initial good response to a corticosteroid injection but have later recurrence of symptoms are also likely to do well with subsequent subacromial decompression. A recent study suggests that ketolorac injected into the subacromial space may actually be more effective than corticosteroid in reducing inflammation and pain (6).

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Subacromial Impingement and Arthroscopic Subacromial Decompression 213

require completion for repair and that are accompanied by intraoperative findings of mechanical impingement.

c SURGICAL TECHNIQUE FOR PERFORMING ARTHROSCOPIC SUBACROMIAL DECOMPRESSION Surgical Planning

FIGURE 15-8.  Patients with impingement characteristically have signifi-

cantly increased subacromial fluid on the MRI scan and may have bursal irregularity of the superior surface of the supraspinatus tendon.

Surgical Indications Patients who remain symptomatic are offered the option of proceeding with ASD. We also perform subacromial decompression in most patients with complete or bursalsided ­partial rotator cuff tears, in some patients undergoing excision of calcium deposits located beneath the anterior ­acromion, and sometimes for patients with partial articularsided rotator cuff tears, particularly those larger tears that

FIGURE 15-9. Rotator cuff strengthening exercises are initially performed by the patient using an elastic cord with the arm at the side.

When performing a subacromial decompression, preoperative planning is critical to determine the correct amount of bone resection. A well-performed arch view is helpful to assess the type of acromion, its thickness, and its overall shape prior to surgery. This allows the surgeon to plan out the appropriate amount of bone resection before going to the operating room. Our goal is to convert a curved or hooked acromion into a flat Type I acromion, leaving the attachments of the deltoid muscle intact anteriorly and laterally. It is important on x-ray to evaluate for any significant inferior spurs on the medial acromion or distal clavicle, which may also be contributing to the impingement. The AP x-ray may also show whether there is significant lateral downsloping of the acromion. Although the primary goal is to remove the impinging elements from the undersurface of the acromion, the other goal is to maintain a sufficient thickness of the acromion to allow proper deltoid support and minimize the risk of postoperative fracture or insufficiency of the acromion. Two special circumstances merit attention preoperatively. The first is the presence of an os acromionale. This normal variation may be present in patients with impingement ­syndrome. These have been classified into different types depending on the location of the unfused apophysis (Fig. 15-10). Most of these patients will have a congenital os acromionale that

FIGURE 15-10. Classification of acromial ossification centers: Pre-­ acromion (PA) is in front of the anterior aspect of the acromioclavicular joint; meso-acromion (MSA) extends anteriorly from the posterior aspect of the ­acromioclavicular joint; and meta-acromion (MTA) extends posteriorly from the posterior aspect of the acromioclavicular joint to the base of the acromion.

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214 SCOI Shoulder Arthroscopy

may be unstable inferiorly, causing impingement on the rotator cuff. These can usually be c­ ategorized most accurately on the axial x-ray. A small anterior os acromionale can simply be excised at the time of decompression. A larger os acromionale involving the ­meso-acromion may be destabilized if the inferior coracoacromial ligament is removed, especially when the acromioclavicular joint is also resected. While a stable meso-acromion can be treated similar to a standard subacromial decompression, resecting the undersurface of the anterior acromion and preserving the fibrous articulation between os acromionale and the remaining acromion, a larger, more unstable fragment may need to be resected, t­aking care to maintain the periosteum and deltoid attachment on the superior surface of the acromion (Fig. 15-11A, B). Occasionally, in a young ­athlete with tenderness over a large os acromionale and a stress fracture–type presentation or history of trauma, fixation

A

A

B

FIGURE 15-11.  A

of the os acromionale fracture with screws across the fracture line may be w ­ arranted rather than subacromial decompression (see Chapter 17). These patients may be distinguished by tenderness over the ­acromion rather than over the rotator cuff, and also by the presence of significant bone edema noted on the T2 axial images on MRI scan. In our experience, this has been a relatively uncommon situation, and most of these patients are treated with standard decompression techniques or excision. A keel acromion may also be present. The keel-shaped acromion is a large spur that runs from the anterior acromion posteriorly to the mid-acromion, rather than the standard subacromial spur that runs from medial to lateral. These are best visualized on the AP x-ray of the shoulder (Fig. 15-12A, B). The name keel acromion refers to the shape, which is ­similar to that of a keel of a sailboat. These can be particularly pathologic, with the keel shape causing significant damage to the

B

large meso-acromion causing impingement symptoms (A). X-ray after complete excision of the meso-acromion (B).

FIGURE 15-12.  An anteroposterior radiograph (A) and an MRI scan ­image (B) showing a keel acromion.

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Subacromial Impingement and Arthroscopic Subacromial Decompression 215

FIGURE 15-13.  A keel acromion is well visualized in the subacromial bursa. underlying rotator cuff. It is important to recognize these on preoperative x-ray, as visualization through the posterior portal may confuse the lateral aspect of the keel Keel Acromion acromion with the medial acromioclavicular joint (Fig. 15-13). Finally, some patients have a significant lateral downslope of the acromion, which may be contributing to the impingement; this should be addressed at the time of the surgery. Therefore, on the basis of the preoperative studies, we can calculate the amount of bone to be resected from the anterior acromion as well as any additional bone resection that will be necessary.

FIGURE 15-14.  A

subacromial decompression is performed with the arm in a 30-degree abduction and neutral rotation position.

through the posterior bursal curtain, maintaining the cannula in a position so that it is approximately midway between the undersurface of the acromion and the top of the supraspinatus tendon. Generally a pop is felt as the cannula enters the bursal space. When the cannula touches the coracoacromial ligament, it is pulled back slightly posteriorly, and the back of the posterior cannula is lifted superiorly, bringing the tip down slightly inferiorly and away from the bursa underlying the acromion. With continued superior pressure on the posterior cannula, the arthroscope is slid in place and will be located under the coracoacromial ligament and the anterior aspect of the acromion and above the supraspinatus tendon (Fig. 15-15). When

Surgical Technique With the arm in the 70-degree abducted position, an initial evaluation of the glenohumeral joint is performed. After completing the glenohumeral arthroscopy, the arm is repositioned SAD into a 30-degree abducted position with neutral extension (Fig. 15-14). The weight is generally increased from the 10 pounds of traction used for the glenohumeral arthroscopy to 15 pounds of weight to open the bursal space more completely. Having the arm in 30 degrees of abduction allows for a wider bursal space, and also makes it easier for the surgeon to work with his or her operating arm draped over the patient’s abducted shoulder.

Posterior bursal curtain

Steps in the Procedure Step 1. The shoulder bursa is entered initially through the posterior portal. The key to this procedure is positioning ­ the arthroscope so that it is located directly inside the bursa. This allows for good visualization and proper assessment of the amount of bursitis and impingement. To achieve proper cannula placement, the cannula is inserted through the posterior portal just below the edge of the posterior acromion. We aim for the midportion of the supraspinatus tendon, and touch the end of the cannula to the superior surface of the rotator cuff. This corresponds roughly to the area of the posterior bursal curtain. The cannula is slightly pulled back and then used to pierce

FIGURE 15-15.  The arthroscope must be appropriately positioned within the bursa to give a good view of the subacromial space. Note the anterior location of the bursa below the acromion and the acromioclavicular ligament.

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216 SCOI Shoulder Arthroscopy

FIGURE 15-16.  When the posterior cannula is positioned properly in the bursa, a “room with a view” is obtained between the overlying acromion and the underlying rotator cuff tendon.

the cannula is properly positioned, a “room with a view” is obtained of the subacromial bursa (Fig. 15-16). Step 2. A switching stick is passed through the posterior cannula and brought out of the anterior portal. A metal cannula is placed over the switching stick and brought into the bursa. As the bursa sits anteriorly on the acromion and extends anterior to the acromion under the coracoacromial ligament, in general the posterior cannula will be inserted more deeply than the anterior cannula (Fig. 15-17). Shaving can then be performed through the anterior cannula as necessary to allow visualization of the acromion and the superior surface of the rotator cuff. Impingement is considered to be present when there is evidence of fraying and fragmentation

FIGURE 15-17.  When properly positioned, the posterior cannula (left) will be positioned deeper into the bursa than the anterior cannula (right). Note the anterior position of the bursa when illuminated by the arthroscope.

FIGURE 15-18.  Fraying on the undersurface of the coracoacromial ligament as well as irregularity of the bursal surface of the supraspinatus tendon confirms the diagnosis of mechanical impingement. of the coracoacromial ligament and synovitis. Often, thickened bursal tissue is present with impingement, and there may be some fraying or frank tearing of the bursal surface of the supraspinatus tendon (Fig. 15-18). When these findings are noted, we will proceed with subacromial decompression. Step 3. At this point, a lateral portal is c­ reated using a spinal needle to determine the appropriate location. Most commonly, the insertion site is on a line drawn perpendicular to the lateral acromion, intersecting the posterior aspect of the acromioclavicular joint (Fig. 15-19A, B). It is important to stay inferior enough to the lateral acromial edge that the acromion does not block the shaver and burr from reaching the undersurface of the bone. This will generally be approximately 3 cm from the lateral edge of the acromion. The position of the portal can also be adjusted anteriorly or posteriorly in the presence of a tear, trying to maintain the portal approximately halfway between the anterior and posterior margins of the tear. Once the proper location has been confirmed under direct visualization with the spinal needle, a skin incision is made, and a 5.5-mm Crystal cannula (Arthrex) is inserted with the obturator. Again, this should be localized between the acromion and the superior aspect of the supraspinatus tendon. Step 4. Limited debridement of the bursal tissue is performed with a shaver to allow visualization of the undersurface of the acromion and the coracoacromial ligament. We then remove the soft tissue on the undersurface of the acromion. This step can certainly be performed using one of many commercially available bipolar electrodes. This allows relatively rapid removal of the ligament with control of hemostasis. However, the bipolar electrode has some significant disadvantages, including a high cost, the potential to heat the irrigating fluid in the subacromial bursa to potentially dangerous levels

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Subacromial Impingement and Arthroscopic Subacromial Decompression 217

A

FIGURE 15-20.  The

shaver is used initially to resect the soft tissue from the undersurface of the acromion prior to performing subacromial decompression.

B

FIGURE 15-19.  A spinal needle is inserted along the previously created

mid-bursal line to ensure that the operative cannula will be properly positioned (A). The needle is visualized within the bursa to confirm appropriate positioning (B).

leading to damage to the soft tissues, articular cartilage, or skin burns as the fluid leaks out of the shoulder, and a fairly large area of resection, which may increase the chance of injury to the deltoid muscle. We prefer an alternative method of removing the soft tissue from the undersurface of the acromion using a 4.0-mm, full-radius resecting shaver. The shaver is used at 2,000 rpm in a forward rotation. By using the tip of the shaver similar to the tip of a pencil on the undersurface of the acromion, it is generally possible to rapidly resect the coracoacromial ligament from the undersurface of the acromion and expose the bone (Fig. 15-20). This is done with the outflow cannula clamped. If the shaver use is confined to removing the soft tissue on the undersurface of the acromion, minimal bleeding occurs. Step 5. Once the outlines of the acromion are well visualized, the hook-tipped electrocautery device is inserted through the lateral cannula (Fig. 15-21). This has the advantage over the bipolar electrode of a limited field of cutting with ability to easily cauterize blood vessels, and a much lower cost than the bipolar electrode. We use the electrode to resect the remaining coracoacromial ligament and anterior

acromial soft tissues off the acromion, beginning on the exposed bone and working out to the edge of the acromion. By maintaining the cautery along the edge of the acromion, bleeding will usually be minimal. Any bleeding that does occur can be readily cauterized. We generally perform this using glycine irrigation fluid, which allows a lower energy level to be used for the cautery; a 15 power setting usually gives optimal results. The tip of the cautery should remain visible as the soft tissue is resected. This prevents overly deep resection, which could lead to damage to the deltoid insertion. Any residual soft tissue on the undersurface of the acromion that was difficult to remove with the shaver can be cross-hatched or ablated with the electrocautery. Step 6. The shaver is reinserted once the soft tissue has been released off the acromial edge. By staying close to the edge of the acromion, any remaining soft tissue can be

FIGURE 15-21. The

hook-tipped electrode is used to complete the resection of the remaining coracoacromial ligament off the anterior and lateral aspects of the acromion. The insulated fine tip allows precise tissue removal at low energy levels.

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218 SCOI Shoulder Arthroscopy

removed. Usually, bleeding will be minimal if the shaver tip remains on the bone. Care is taken not to stray into the deltoid muscle itself or to go too deeply into the coracoacromial ligament. The coracoacromial ligament is not transected, and is allowed to remain attached to the undersurface of the deltoid so that it can reconstitute itself after the decompression. At the conclusion of the shaving, the acromion should be well visualized (Fig. 15-22). The electrocautery is then reinserted one final time to cauterize any remaining areas of bleeding. Step 7. At this point, we introduce the burr into the bursa through the lateral cannula. The outflow tube is opened anteriorly to allow outflow through the anterior cannula rather than using the suction on the burr. This prevents the burr from becoming clogged with bone debris during resection. We use a 4.0-mm, ovalshaped burr. The size of the burr allows an estimation of the amount of bone to be resected, based on the measurements obtained on the preoperative x-rays. For example, if a 6-mm resection is desired, then the initial resection removes 150% of the 4-mm burr width of bone, beginning on the anterolateral aspect of the acromion (Fig. 15-23A–C). Care is taken when burring to avoid injury to the anterior periosteum and to the deltoid. The bone is simply peeled off these structures without cutting them. Resection begins laterally and extends medially until a completely flat surface has been achieved

FIGURE 15-22.  The

acromion has been well exposed prior to bone

removal.

A

6 mm

C

B

4 mm burr width

6 mm

FIGURE 15-23. The desired amount of anterior acromial resection is determined from the arch view (A). The 4-mm burr is used to measure the amount of bone to be resected (B). The appropriate amount of bone resection is initiated at the anterolateral corner of the acromion (C) (see text for details).

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Subacromial Impingement and Arthroscopic Subacromial Decompression 219

A

B

FIGURE 15-24.  The desired amount of the acromion has been resected flat anteriorly, and the lateral edge has been tapered by the burr (A, B).

all the way over to the distal clavicle. The anterior edge of the acromion is resected to the predetermined depth. The acromion posterior to the initial anterior resection will be smoothed down while viewing from the lateral portal and is left intact at this point. Once the anterior resection is completed, we use the tip of the burr to resect the lateral overhang of the acromion, beginning at the anterolateral corner and extending more posteriorly. The lateral resection measures 4 to 5 mm in width. The resection can safely be carried laterally to the level of the deltoid insertion, but the deltoid insertion is preserved (Fig. 15-24A, B). Step 8. Once the resection has been completed working through the lateral portal, the arthroscope is shifted into the lateral portal and the instruments are shifted into the posterior portal. The shaver is introduced and used to lightly remove any remaining soft tissue that may be visualized on the acromion, particularly posteriorly. If a resection of the distal clavicle is planned, soft tissue can also be removed from the undersurface of the clavicle at this stage, in preparation for the subsequent resection of the distal clavicle. Once again, we use cautery to control any bleeding. The burr is inserted through the posterior cannula. There is usually a prominent portion of the acromion remaining behind the level of the initial resection (Fig. 15-25). Also, there is frequently a prominent residual medial facet of the acromion remaining posterior to the area of the initial resection. First, we resect the medial facet of the acromion flush with the previous resection. Then, we use the flat part of the burr, sweeping it from a lateral to a medial direction, and any residual prominence behind the level of the previous anterior resection is smoothed down (Fig. 15-26). Resection continues until a flat acromial undersurface has been achieved, taking care not to resect any more of the previously resected anterior acromion. Depending on the shape of the posterior acromion, this is either tapered into the curved portion of the acromion or a completely flattened surface of the acromion may be achieved. Once the majority of the bone has been resected, the burr can be placed on a reverse setting. Using the burr on the reverse and using the side of the burr sheath to ensure flatness, a very smooth, even resection of the acromion can generally be obtained (Fig. 15-27). Step 9. After the acromioplasty has been completed, attention can be directed as necessary to the acromioclavicular

FIGURE 15-25. When viewed laterally, there is usually a residual prominence of the medial acromion behind the previous anterior resection.

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220 SCOI Shoulder Arthroscopy

FIGURE 15-26.  Using the burr, the remaining middle portion of the acromion is resected back, flush with the previous anterior acromial resection.

joint. If the inferior clavicle is prominent, it can be beveled down slightly with the shaver to prevent any impingement on the rotator cuff tendon (Fig. 15-28). The clavicle angles caudally as it moves more medially, and a completely flat appearance is not necessary. Any bony prominences are removed, and care is taken not to move too far medially with the resection and cause potential damage to the coracoclavicular ligaments (Fig. 15-29). If preoperative studies have indicated that resection of the distal clavicle will be necessary, then we perform the procedure at this time (see Chapter 16). Step 10. Once a satisfactory decompression has been achieved, the arthroscope can be shifted back to the posterior portal to ensure that there is a good resection of the acromion when viewed through both perspectives. Any residual acromial overhang or irregularities can be smoothed out at this point. After the bone work has been completed, the traction is then adjusted to the “midposition,” which is a position of approximately 45 degrees of abduction of the arm

FIGURE 15-28.  Any prominence of the undersurface of the clavicle can be resected back at the time of subacromial decompression.

(Fig. 15-30). This makes the rotator cuff easier to access, and the bursa is subsequently resected using the shaver and electrocautery as necessary until the rotator cuff is well visualized. It is important to resect any hypertrophic bursal tissue overlying the rotator cuff to prevent any residual pain resulting from the bursa. If rotator cuff repair is required, then this is subsequently performed (see Chapter 20). Following the procedure, the portals are closed using a 3-0 Vicryl subcutaneous suture and Steri-strips. The patient’s arm is placed into a neutral rotation UltraSling.

Postoperative Care We perform our subacromial decompressions under general anesthesia. Most of these patients will have a preoperative supraclavicular nerve block placed under ultrasonic guidance for postoperative pain management. When the patients return home, they support the arm in the UltraSling until the

FIGURE 15-29.  The FIGURE 15-27.  Arthroscopic view through the lateral portal of the flat subacromial resection.

subacromial decompression and resection of the inferior distal clavicle have been completed. Care is taken to preserve the acromioclavicular ligaments and to limit resection to the area of the clavicle below the articular surface.

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Subacromial Impingement and Arthroscopic Subacromial Decompression 221

A

FIGURE 15-30.  A “mid-bursal” position in 45 degrees of abduction and neutral extension improves access to the rotator cuff once the subacromial decompression has been completed. block has resolved. The patient is encouraged to begin active motion of the elbow in both flexion and extension, and pronation and supination, and to squeeze a soft ball with the hand of the operated arm as soon as possible. We instruct the patient to wear the sling for comfort only, and to begin removing the sling as tolerated for some initial pendulum exercises to the shoulder. Our goal is to have the patient out of the sling within the first several days. As the patients become more comfortable, they are encouraged to progressively increase passive range of motion, followed by active assisted motion, and then active motion as tolerated. The patient is allowed to remove the bandages and shower in 48 hours. We have them work independently to regain motion for the first 2 weeks. They return for follow-up in the office 2 weeks after surgery. At the time of the first postoperative visit, repeat x-rays of the shoulder, including arch and AP views, are obtained to ensure that the patient has an appropriate subacromial decompression without any residual spurring or evidence of damage to the structural integrity of the acromion (Fig. 15-31A, B).

B

FIGURE 15-31.  Arch

view of the preoperative acromion (A) and the completed subacromial decompression (B) showing a flat acromion and good remaining acromial thickness.

Physical Therapy

Results and Follow-up

Most of our patients begin a course of formal physical therapy 2 weeks after surgery. Initial efforts focus on reducing pain and inflammation and regaining full passive motion in the shoulder. Once passive motion has been achieved, the patient begins a strengthening program. This is initially performed with the arm at the side. In general, it will be at least 6 weeks after decompression until the patients are comfortable lifting any significant weight in a position at or above shoulder level. The expected recovery time after surgery is approximately 3 months for a simple decompression. At this point, the patients are allowed to return to full sports and other activities as tolerated, provided they have good range of motion and strength.

Good results with ASD have been reported (7,8). Appropriate treatment of a symptomatic meso-acromion with fixation, decompression, or resection has also been shown to result in significant improvement in pain and function of symptomatic patients (9). As noted above, there has been increasing controversy as to whether subacromial decompression is required in the setting of rotator cuff repair (4,5). We continue to believe that in patients with significant mechanical evidence of impingement, appropriate clinical findings, and the presence of rotator cuff pathology involving the bursal surface, subacromial decompression is an effective and important procedure to perform.

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222 SCOI Shoulder Arthroscopy

Potential Complications and How to Avoid Them It is important for the surgeon to follow a reproducible, stepwise technique as outlined above to minimize the chance of complications. Perhaps the most common complication noted after subacromial decompression is incomplete bone resection. This generally occurs in one of two areas. The anterolateral corner may not be adequately resected because of failure to completely release the coracoacromial ligament all the way out laterally. The acromion generally extends laterally superior to the insertion of the coracoacromial ligament. This may lead to the erroneous identification of the medial edge of the coracoacromial ligament insertion as the lateral edge of the acromion. Failure to adequately peel away the coracoacromial ligament from the undersurface of the acromion may, therefore, result in bone being left in the anterolateral corner of the acromion. This remaining bone may cause residual impingement. A second area where resection may be incomplete is the area of the medial acromial facet. As noted above, a keel-shaped acromion may be particularly difficult to treat. This is because the shape of the keel prevents the burr from accessing the medial acromion when the burr is introduced through the lateral portal (Fig. 15-32). Once the keel-shaped acromion has been recognized, it is helpful to initially use the burr to resect down the keel while working through the lateral portal and visualizing posteriorly. Once the keel has been flattened down to level with the remainder of the acromion, subacromial decompression can proceed in the usual fashion as previously described. A second complication is excessive bone resection, which could lead to acromial fracture. This is particularly likely in individuals with a relatively small, thin acromion. The most difficult acromion to decompress properly has a curved morphology when viewed on the arch view preoperatively. The advantage of the technique that we have described is that it prevents inadvertent overresection of the acromion as may occur when the posterior acromion is used as a guide

to determine the anterior resection. Basing the resection on the undersurface of the curved posterior acromion will result in overresection of a large portion of the anterior acromion, leaving a thin remaining edge in the midportion (Fig. 15-33). Recognizing this preoperatively allows the bone to be precisely resected from the anterior acromion, preserving the acromial curve posteriorly and ensuring an appropriate bone resection. Care should be taken when performing a decompression to avoid inadvertent release of the deltoid. This can potentially weaken the shoulder and may be difficult to reattach. By using the shaver initially on the bone itself, and carefully working out to the edge of the acromion with a cautery, this problem can be avoided. It is important when using the electrocautery to avoid plunging too deeply into the soft tissues around the edges of the acromion. The electrode tip should always be visualized when using the cautery to prevent inadvertent release of the deltoid. Also, when the bone is removed with a burr, resection should be performed only down to the edge of the periosteum and deltoid. Postoperatively, stiffness is a concern following subacromial decompression. Many cases of stiffness following subacromial decompression are undoubtedly due to an error in preoperative diagnosis, particularly diagnosing a patient with early adhesive capsulitis as having impingement. This should be determined at the time of surgery by first performing examination under anesthesia. If the patient has significant loss of motion in the shoulder, then manipulation under anesthesia may be necessary. These patients will also have the characteristic findings of synovitis within the glenohumeral joint. In such cases, the synovitis may be resected and the rotator interval released with capsular release as necessary at the time of manipulation (see Chapter 6). We generally will not proceed with subacromial decompression in these patients, and instead will begin a rehabilitation program to regain motion. In most of these cases, impingement is unlikely to be a problem once the range of motion has been achieved again. When the patient does not have evidence of any adhesive capsulitis during examination under

Acromial keel

FIGURE 15-32.  A keel acromion may prevent the burr from reaching the medial acromial facet.

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Subacromial Impingement and Arthroscopic Subacromial Decompression 223

Over-resection of the acromion due to using posterior acromion as cutting block

Desired amount of acromial resection 5 mm

FIGURE 15-33. Using

a cutting block technique may result in overresection of the anterior acromion in a patient with a curved acromion.

anesthesia or diagnostic arthroscopy, but still becomes stiff after subacromial decompression, then the stiffness will usually respond well to aggressive physical therapy. In our experience, this is a relatively uncommon problem. In these cases, recovery time after surgery may be prolonged, often requiring up to 6 to 9 months to regain motion and function in a stiff shoulder versus 2 to 3 months in a patient who does not develop stiffness. In rare cases when the patient fails to progress with physical therapy and the motion loss persists after 6 months, we will consider proceeding with a repeat arthroscopy of the shoulder with lysis of adhesions and possible capsular release (see Chapter 6). While a gentle manipulation can be attempted at the time of surgery, we prefer to avoid forced manipulation as this can sometimes lead to avulsion of fragments of the acromion from the thickened subacromial fibrosis, which will usually be present. Although subacromial decompression has a high success rate in patients with an accurate diagnosis of impingement, persistent pain may occur even after the decompression. This may be due to additional undiagnosed pathology such as acromioclavicular joint arthritis, rotator cuff tearing, or biceps problems. If a partial resection of the inferior surface of the distal clavicle has been performed, some patients may have persistent acromioclavicular pain. Some authors have described a higher incidence of this problem after partial resection than after complete resection (10). In these patients, selective anesthetic injection into the acromioclavicular joint may relieve the pain, and may indicate that additional surgery will be necessary to completely resect the distal clavicle. Our experience has echoed that of other surgeons who noted no increase in acromioclavicular pain after a careful inferior resection of the distal clavicle (11). Such pain can often be avoided by minimizing the resection

of the inferior distal clavicle, particularly by trying to avoid destabilizing the distal clavicle by excessively releasing the ligaments around the distal clavicle at the time of the acromioclavicular surgery. Further workup may be necessary in some patients with persistent pain after subacromial decompression to make sure that there is no residual pathology, and in some cases to rule out a chronic regional pain syndrome. A special complication of concern may occur in patients with massive rotator cuff tears. Particularly with an open subacromial decompression, superior escape of the humeral head anteriorly and laterally has been reported. After an open decompression, anterior escape usually results in an avulsion of the anterior deltoid and subluxation of the humeral head anteriorly and laterally to the acromion. We have not encountered this following an ASD. However, in a case of a massive rotator cuff repair that could go on to failure and subsequent escape, a more limited decompression is performed, removing any irregularities from the undersurface of the bone, but leaving the coracoacromial ligament attached laterally. This decreases the chance of escape.

Pearls for Ensuring a Good Result after Subacromial Decompression 1. Ensure that an accurate diagnosis of impingement syndrome is made and is consistent with findings on imaging, response to a corticosteroid injection, and that the patient has failed a course of conservative treatment. Be particularly vigilant in diagnosing possible adhesive capsulitis prior to surgery, which, if present, will actually worsen after subacromial decompression.

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224 SCOI Shoulder Arthroscopy

2. It is important to have a good arch view and to measure the acromion preoperatively to determine the extent of bone resection. It is also important to pay attention to the acromial morphology. A thin, curved acromion will need to be treated differently than a flat, thick acromion with an anterior hook. 3. Good visualization is important to allow adequate bone resection. This can be facilitated using an arthroscopic pump, hypotensive anesthesia, and electrocautery to limit bleeding. 4. When performing acromial resection, always perform resection of the anterior acromion first, using the burr to ensure the correct amount of resection on the basis of preoperative studies. This sets the depth of the anterior acromial resection and prevents inadvertent overresection as long as no further anterior bone is resected when viewing through the lateral portal and working posteriorly. 5. While viewing posteriorly and working through the lateral portal, bevel the lateral edge of the acromion to just above the level of the deltoid insertion. This makes it much easier to visualize the lateral acromion when viewing through the lateral portal, and ensures that any lateral overhang is removed. 6. After completing the bone resection, make sure the thickened bursa is adequately resected over the rotator cuff tendon to prevent residual pain and possibly to minimize stiffness postoperatively. 7. In general, we attempt to leave the coracoacromial ligament in place on the undersurface of the deltoid. This allows the ligament to reconstitute on the bottom of the acromion, and this may help to prevent subacromial escape. It is permissible, however, if the ligament is very large and significantly frayed as it passes over the rotator cuff tendon, to release the ligament tension in several areas and thereby minimize the chance that the prominent ligament may cause residual impingement. 8. The patient should be moved as quickly as possible after surgery. We limit the use of a sling and begin early range of motion as tolerated. This helps prevent postoperative stiffness.

Frequently Asked Questions 1. Do all patients with rotator cuff tears require subacromial decompression? No. We generally decompress patients with prominence of the anterior acromion who also have associated cuff tears involving the bursal surface. Patients with articularsided partial tears or acute traumatic complete tears without significant impingement findings intra-operatively, such as fraying on the undersurface of the coracoacromial ligament and acromion, often do well with rotator cuff repairs without concomitant decompression.

2. How much acromion should be resected? This should be determined preoperatively from the arch view. The goal is to achieve a smooth, flat Type I acromion while preserving the structural integrity of the bone and the deltoid attachments. A stepwise technique as outlined above that allows the amount of resection to be accurately measured helps to ensure a good resection. 3. Should the coracoacromial ligament be resected? No. We prefer to leave the ligament intact and attached to the undersurface of the deltoid. Partial release of the tension on the ligament may be necessary, however, if the ligament is very tight and appears to be contributing to the impingement.

References 1. Neer CS. Anterior acromioplasty for chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg 1972;54A:41–50. 2. Bigliani LU, Morrison DS, April EW. The morphology of the acromion and its relationship to rotator cuff tears. Orthop Trans 1986;10:216. 3. Wuh HCK, Snyder SJ. A modified classification of the supraspinatus outlet view based on the configuration and the anatomic thickness of the acromion. Arthroscopy 1992;8(3):402. 4. Ellman H. Arthroscopic subacromial decompression: analysis of one to three year results. Arthroscopy 1988;4:241–249. 5. Patel VR, Singh D, Calvery PT, et al. Arthroscopic subacromial decompression: results and factors affecting outcome. J Shoulder Elbow Surg 1999;8(3):231–237. 6. Min KS, St Pierre P, Ryan PM, et al. A double-blind randomized controlled trial comparing the effects of subacromial injection with corticosteroid versus NSAID in patients with shoulder impingement syndrome. J Shoulder Elbow Surg 2013;22(5):595–601. 7. Ketola S, Lehtinen J, Arnala I, et al. Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome?: a two-year randomised controlled trial. J Bone Joint Surg Br 2009;91(10):1326–1334. 8. Ketola S, Lehtinen J, Rousi T, et al. No evidence of long-term benefits of arthroscopic acromioplasty in the treatment of shoulder impingement syndrome: five-year results of a randomised controlled trial. Bone Joint Res 2013;2(7):132–139. 9. Harris JD, Griesser MJ, Jones GL. Systematic review of the surgical treatment for symptomatic os acromiale. Int J Shoulder Surg 2011;5(1):9–16. 10. Fischer BW, Gross RM, McCarthy JA, et al. Incidence of acromioclavicular joint complications after arthroscopic subacromial decompression. Arthroscopy 1999;15(3):241–248. 11. Kharrazi FD, Busfield BT, Khorshad DS. Acromioclavicular joint reoperation after arthroscopic subacromial decompression with and without concomitant acromioclavicular surgery. Arthroscopy 2007;23(8):804–808.

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16

The Acromioclavicular Joint c INTRODUCTION The acromioclavicular (AC) joint is a subcutaneous diarthrodial joint that can be a very common source of problems encountered in an orthopedic shoulder practice. Acute and chronic AC separation injuries, degenerative joint disease, osteolysis, and symptomatic os acromial disease combine to create a wide array of operative and nonoperative shoulder problems. This chapter discusses the clinical evaluation of the AC joint, nonoperative management, and arthroscopicassisted treatment of acute and chronic pathology.

c ACROMIOCLAVICULAR JOINT SEPARATIONS AC joint stability is maintained through both static and dynamic constraints. The AC ligaments provide the greatest restraint to displacement in the anterior and posterior directions. Specifically, the superior AC ligament accounts for greater than 50% of the resistance to posterior translation, while the posterior ligament accounts for 25% (1). Vertical stability predominantly comes from the coracoclavicular (CC) ligaments: the conoid ligament posteromedially and the trapezoid ligament anterolaterally. The conoid ligament plays a primary role in constraining anterior and superior displacement of the clavicle, while the trapezoid ligament works to minimize axial compression toward and into the acromion. The mechanism of injury to the AC joint is usually direct, involving a fall directly onto the tip of the shoulder. Occasionally, indirect forces can damage the AC joint, such as a fall onto an outstretched hand. The patient usually presents with localized pain and possibly deformity over the top of the shoulder area. AC joint separations have been divided into six subtypes (Fig. 16-1). A Type I injury, as classified

by Rockwood, consists of a partial tear of the capsular ligaments of the AC joint. There is no significant displacement of the clavicle in relation to the acromion. When inspecting the joint, it may appear swollen and sometimes slightly discolored or bruised. It is usually quite tender when palpated, and there may be crepitation with motion such as shoulder shrugging. A Type II injury is more severe, consisting of additional damage with partial tearing of the CC ligaments. In this situation, the AC joint is slightly subluxed, with the clavicle displaced superiorly and posteriorly in relation to the acromial facet. The opposing surfaces of the facets are still in contact but slightly misaligned. Superior displacement is less than 100% of the diameter of the distal clavicle, and the radiographic CC distance is increased by less than 20%. Normal CC distance can be measured from the contralateral shoulder, or an accepted distance of 1.1 to 1.3 cm can be used. Physical examination results are similar to those for Type I, but there may be a slightly pronounced prominence of the distal clavicle. Conservative treatment is appropriate for Type I and II separations, as these patients nearly always improve back to a baseline level. We do occasionally see patients, however, who develop chronic AC joint arthrosis after suffering Type I or II separation. A Type III injury involves tearing of both the AC ligaments and the CC ligaments. The clavicle will be displaced superiorly and posteriorly in relation to the acromion, greater than 100% of the diameter of the distal clavicle and between 25% and 100% of the CC distance. In these patients, the deformity is usually obvious, and the pain in the first few days after the injury is severe. The clavicle may tent the skin, especially if the bone has penetrated and buttonholed through the trapezius muscle. Management of acute Type III AC separations is still an area of major controversy. Type IV (the lateral clavicle is displaced posteriorly through the trapezius), Type V (the clavicle is elevated greater than 300% of the diameter of the distal clavicle, greater than 100% of the CC 225

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226 SCOI Shoulder Arthroscopy

Type I

Type II

Type III

Type IV

Type V

Type VI

FIGURE 16-1.  AC joint separation types: Type I represents a strain of the acromioclavicluar (AC ) ligaments without displacement or injury to the coracoclavicular (CC) ligaments. Type II represents a tear of the AC ligaments, possible slight joint subluxation, and a strain of the CC ligaments. Type III represents a tear of both the AC and CC ligaments, with complete displacement of the AC joint. Type IV represents a tear of the AC and CC ligaments with posterior displacement of the clavicle into the trapezius muscle. Type V represents complete AC and CC tearing with severe superior displacement of the clavicle greater than double (100%) the normal CC distance. Type VI represents a rare locked inferior displacement of the clavicle underneath the coracoid process.

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Chapter 16

distance, and is associated with rupture of the deltotrapezial fascia), and Type VI separations (rare injuries with the distal clavicle lying in a subacromial or subcoracoid position) are all known to do poorly with conservative treatment, and surgical reconstruction is standardly recommended.

c SURGICAL CONSIDERATIONS FOR ACUTE AC JOINT INJURIES Surgical intervention is indicated for patients with Type IV, V, and VI shoulder separations. It should be noted that without accurate x-rays, including anteroposterior (AP), scapular Y, axillary lateral, and Zanca views, as well as a physical exam, many Type IV and V separations can be missed and incorrectly diagnosed as Type III. For example, a simple shoulder shrug test can be helpful in determining whether the deltotrapezial fascia has separated from the clavicle, and thereby help differentiate a Type V injury from a Type III injury: If the shoulder shrug cannot reduce the AC joint, the deltotrapezial fascia can be considered to be disrupted, and a Type V injury is present. Axillary lateral x-ray is crucial in identifying posterior clavicular displacement, thereby differentiating a Type IV injury requiring surgery from a Type III. For Type I and II separations, conservative treatment is often successful: ice, rest, nonsteroidal medication, and occasionally corticosteroid injections. If painful symptoms persist, a surgical distal clavicle excision can be performed. The incidence of residual symptoms after Type I and II AC joint injuries is actually higher than might be expected: Up to 50% of patients can be expected to have symptoms, up to 75% of patients can be expected to have positive physical exam findings, up to 50% of patients treated nonoperatively will go on to develop posttraumatic arthritis, and at least 25% of patients will require surgery within 2 years, according to published literature (2–4). For acute Type III AC separations, nonsurgical treatment is currently still the standard of care. In addition to the above conservative protocol, we generally recommend a course of structured, active physical therapy to help the patients regain their range of motion but, more importantly, to rebalance and reeducate the periscapular muscles. Complete tearing of the CC ligaments disrupts the normal anatomy and mechanics of the upper extremity, often leading to chronic trapezius and scapular pain. We currently do not use any braces to try to reduce or stabilize acute Type III injuries, as they have been associated with recurrence of deformity, skin ulcerations, poor compliance, and muscular atrophy. It is our recommendation, however, that each case of Type III injury be managed individually. While the majority of the published literature suggests that surgical reconstruction fares no better than conservative management, the literature does not suggest that all patients treated conservatively will have good or excellent results. Similarly, with the advent of new and improved reconstruction devices and techniques, our ability to create stronger, longer-lasting reconstructions is also improving. In addition, there does seem to be a benefit in acute intervention, taking advantage of the body’s natural healing response, when reconstructing Type III injuries: The literature suggests that chronic reconstructions have a

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The Acromioclavicular Joint 227

higher failure rate and less favorable clinical outcome than acute reconstructions (5). In our clinical experience with revision of failed allograft reconstructions, the quality of the allograft has been very poor at the time of revision surgery. Integration of the allograft tissue into a strong ligament is a very slow process. Therefore, it is extremely important that the primary stabilization implants be very strong in any case of chronic reconstruction. In effect, there does appear to be an “outcomes cost” in waiting for an acute injury to become chronic before surgical intervention. Owing to these factors, we currently offer surgical reconstruction to those patients with acute Type III injuries who may be less likely to do well conservatively: irreducible displacement, overhead athletes, physically demanding occupations, or those patients who clearly understand the risks and request surgery for cosmetic and/or functional reasons. The current literature is inconclusive regarding the ideal technique for treating acute or chronic AC separations. Classic and modified Weaver-Dunn procedures have been shown to be suboptimal in terms of biomechanical strength and clinical outcomes. Other previously described procedures included direct fixation across the AC joint or screw fixation directly into the coracoid, but these procedures are often complicated by hardware failure. More recently, a more anatomical, biologic approach has been taken to reconstruct both the trapezoid and conoid ligaments, which, in combination with minimally invasive stronger fixation devices, provides new and improved solutions to a difficult problem. For acute (1.8 mm thick) •  Suture hook system for shuttling •  Four cannulas: posterior, anterior, anterior lateral (8–8.5 mm diameter, for graft passage), and posterior lateral portal/cannula (for viewing) •  Knotted measuring suture: knots at 1-cm increments •  6–7 #2 braided sutures (4–5 STIK knots) •  2–3 push-in-style suture anchors (lateral fixation)

c SURGICAL TECHNIQUE “The full-length video of the surgical technique can be accessed by scanning the QR code.” Essential equipment is summarized in Table 22-1.

RCR w Augment

Positioning and Preparation The all-arthroscopic rotator cuff surgery is performed in the lateral decubitus position. The standard position using 10 pounds of balanced suspension in 70 degrees of shoulder abduction is used for glenohumeral work, 15 pounds and 15 degrees of abduction is used for standard bursal surgery, and 10 pounds in approximately 45 degrees of abduction is used as a “midposition” for accessing the lateral aspect of the greater tuberosity and placement of lateral anchors. A complete 15-point arthroscopic glenohumeral evaluation is performed, viewing from both the posterior and anterior portals. Releases of the rotator cuff are initially performed from within the glenohumeral joint space. In the bursal space, with the arm in adduction, a full evaluation of the anatomy is performed. An anterolateral working cannula and a posterior lateral viewing portal are both established (Fig. 22-2). The anterolateral working cannula will be used for graft passage as well as placement of the lateral anchors. When positioning this cannula, be sure that it will not only have smooth access to the subacromial space, but also be well aligned for placement of suture anchors lateral to the edge of the greater tuberosity. The posterior lateral viewing portal should be placed just posterior to the middle of the tear such that it will have complete visualization throughout the case, including the entire tear, the greater tuberosity, and the anterolateral cannula as it enters the subacromial space.

Rotator Cuff Repair An arthroscopic rotator cuff repair is performed using customary arthroscopic techniques, including tissue releases and margin convergence sutures when needed. Most tears can be completely repaired back to bone. We prefer to use the “SCOI Row” technique: a medially-based single row of triple-loaded suture anchors, combined with bone marrow

FIGURE 22-2.  Recommended portal and cannula placement for rotator cuff augmentation. There are standard anterior and posterior working cannulas (blue, 7 mm), a posterior lateral portal for the arthroscope, and a larger (yellow, 8 mm) anterior lateral cannula that will be used for graft passage and lateral anchor placement. venting of the lateral greater tuberosity, as described earlier in this book. However, the augmentation technique described here was developed so that it could be used in conjunction with any type of rotator cuff repair: single row, double row, transosseous equivalent, margin convergence sutures, etc. We feel it is important that the surgeon be able to use any and all techniques available to perform the best primary repair possible, prior to augmenting the construct.

Graft Measurement and Preparation Before repair, the tendon is debrided, and the graft size is measured in both anterior-to-posterior and medial-to-lateral dimensions. Medial-to-lateral retraction is especially important, as the graft must be large enough to span this defect should the rotator cuff native tissue fail to heal and retract. To measure, we use a knotted suture as a measuring device. A size 0 braided suture is prepared preoperatively with six knots, spaced exactly 1 cm apart (Fig. 22-3). The measuring suture is held with a grasper on one end, while the other end

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326 SCOI Shoulder Arthroscopy

FIGURE 22-5.  Prepared graft: The graft has been cut to an oval size big FIGURE 22-3.  Using a #0 braided suture, a measuring suture is created by

placing six knots exactly 1 cm apart. The first knot is larger with multiple throws to prevent it from sliding through the knot pusher. All other knots are singlethrow knots such that they can be easily slid through the knot pusher eyelet.

is passed loaded in a knot pusher such that the suture with its knots can easily slide back and forth through the eyelet of the knot pusher. Only two measurements are required before the graft can be cut: anterior to posterior along the articular margin, and medial to lateral (prior to repair) from the edge of the retracted tendon to the lateral extent of the greater tuberosity (Fig. 22-4A, B). The graft is intentionally oversized by 3 mm per side to allow for placement of the sutures. For example, a tear measuring 3.0 × 3.0 cm will require a graft 3.6 × 3.6 cm. Most grafts require six suture points of fixation. They are evenly spaced, like the odd numbers on the face of a clock. Two sutures will be used for lateral fixation into the greater tuberosity. These are simple #2 braided permanent sutures, passed through the tissue with their ends tied together to prevent pullout from the graft. The other four sutures are short-tailed interference knot (STIK) sutures, evenly spaced

A

enough to cover the entire extent of damage. Six sutures have been evenly placed circumferentially around the graft: four STIK sutures for posterior, medial, and anterior fixation, and two simple sutures for lateral fixation. The midpoint of the lateral edge is marked with a reference line.

for posterior, medial, and anterior tissue fixation. A midline ink mark is placed on the lateral aspect of the graft as a reference point (Fig. 22-5). A STIK suture consists of a mulberrytype knot tied to the end of a #2 suture, which is then subsequently passed through the graft with a needle, leaving the knot and its 5-mm tail on top (Fig. 22-6). STIK knots are very helpful for permitting graft control while pulling the graft through the cannula into the shoulder without allowing suture pullout. Dermal allografts have two sides: a basement membrane “smooth” side and a reticular “fuzzy” side. Knots are set on the smooth basement membrane side (the reticular side will be oriented to be down against the bone/tendon).

B

FIGURE 22-4.  Tear size measurement. After debridement and tuberosity preparation, the size of the tear is measured with the measuring suture in both anterior-to-posterior (A) and medial-to-lateral (B) directions. (c) 2015 Wolters Kluwer. All Rights Reserved.

Chapter 22

FIGURE 22-6.  “STIK” sutures: Short-tailed interference knot sutures are shown. Four simple throws are initially placed in a loop of #2 braided suture, the knot is tightened, and an additional throw is then added to the side of the knot for bulk.

Suture Passage Once the rotator cuff has been repaired, and the graft has been measured, cut to size, and prepared with STIK sutures, it is time to pass the sutures through the tissue and bring the graft into the shoulder. The extent of the tear laterally is confirmed with the knotted suture (Fig. 22-7). Passing sutures is the most technically challenging part of the case, requiring astute attention to detail from both the surgeon and the assistant.

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Rotator Cuff Repair with Augmentation 327

The first step is to bring the graft adjacent to  the anterolateral cannula. Clip a wet towel around the upper arm and carefully place the graft upon the towel. Orient the graft anatomically. Sequential suturing begins posteriorly and progresses medially and anteriorly. Have the assistant select the most posterior STIK suture and hold it. Clip the graft’s two lateral sutures to the towel with a hemostat to stabilize it and to prevent it from becoming twisted (Fig. 22-8). Using appropriately curved suture hooks, the four STIK sutures are sequentially shuttled down the anterolateral cannula and through the rotator cuff. Beginning posteriorly, a suture hook is passed “through-and-through” the rotator cuff tissue, and a shuttling suture or Super Shuttle (Conmed/­Linvatec, Largo, FL) is brought out of the anterolateral cannula with a grasper. The free end of the corresponding posterior STIK suture is shuttled through the cuff tendon and back out of the ­posterior cannula (Fig. 22-9). The shuttling technique is repeated, progressing medially and then anteriorly, shuttling the three other STIK sutures. Sharp, curved suture hooks are necessary for the medial stitches, and each stitch must be properly placed to correspond to the placement of the STIK suture on the graft. To avoid entanglement: It is absolutely essential that each STIK suture must be passed parallel to the previously placed sutures. Any crossing of the suture shuttle with the existing

FIGURE 22-7.  Schematic of a large rotator cuff tear, after repair with three suture anchors and three margin

convergence sutures. The size of the graft necessary is confirmed by measuring the anterior-to-posterior, as well as medial-to-lateral, distances with the knotted suture.

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328 SCOI Shoulder Arthroscopy

successfully grasp the suture shuttle. Once the suture shuttle is grasped successfully, the grasper retrieves it back out of the cannula where it can be loaded and used to shuttle its corresponding STIK suture across the tissue. In most cases, two sutures are passed via the posterior portal, and two sutures are passed via the anterior portal (Fig. 22-10).

Graft Insertion

FIGURE 22-8.  In preparation for insertion, the graft is placed adjacent to the anterior lateral cannula. The two lateral simple sutures are clipped to a moist towel to stabilize the graft.

STIK sutures will result in graft entanglement. To avoid entanglement, the mantra is to “stay anterior.” When suturing in a posterior-to-anterior direction, if each subsequent suture shuttle can be passed to the grasper anterior to all prior sutures within the cannula, entanglement cannot occur, and any number of sutures can be passed without problems. To “stay anterior,” the key is keeping the grasper anterior to all sutures as it enters, goes down, and exits the anterolateral cannula. Sutures within the cannula are pulled posterior while the grasper is manually passed down the anterior aspect of the cannula. Under direct visualization with the arthroscope, the grasper enters the shoulder anterior to the prior sutures and then stays anterior until it can

After passing all of the STIK sutures through the tissue, the graft is ready for insertion through the anterolateral cannula. The slack is pulled out of all the sutures, thereby docking the graft at the aperture of the anterolateral cannula. The graft is rolled onto itself to facilitate graft passage through the cannula (Fig. 22-11). A  “push-pull” technique is used: As the graft is pushed down the cannula using a small, thin grasper, the STIK suture ends are pulled from their respective posterior and anterior cannulas. Once the graft enters the shoulder, each suture end is sequentially tightened to unfold the graft and cover the repair site. Each STIK knot is then sequentially retrieved and tied, ­stabilizing the graft anteriorly, medially, and posteriorly (Fig. 22-12).

Lateral Fixation Two push-in suture anchors are used to stabilize the lateral edge of the graft over the lateral greater tuberosity. To facilitate access to the lateral tuberosity, the arm is abducted to a “midposition” of approximately 45 degrees. The midline ink mark on the graft is now a helpful reference to maintain orientation during anchor placement. All four limbs of the lateral sutures are still in the

FIGURE 22-9.  The first “throughand-through” stitch through the posterior 9 o’clock region of the repaired tissue. The Shuttle is used to pass the corresponding 9 o’clock STIK suture through the tissue and out of the posterior cannula.

11 9

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Rotator Cuff Repair with Augmentation 329

FIGURE 22-10.  The suture management process: Working from posterior to anterior, the four STIK sutures on the graft are sequentially passed through the repaired tissue. To avoid entanglement, each subsequent stitch must be passed and grasped anterior to the prior sutures within the cannula.

11 9

FIGURE 22-11.  To prepare for graft insertion, the graft is carefully folded and the STIK suture slack is removed, bringing the graft adjacent to the anterior lateral cannula.

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330 SCOI Shoulder Arthroscopy

FIGURE 22-12. After

graft insertion, the four STIK sutures are each tied with sliding-locking knots, securing the graft posteriorly, medially, and anteriorly. The lateral sutures will be used to secure the graft laterally with suture anchors.

anterolateral cannula. The two limbs for the posterior lateral suture are taken into the posterior cannula. A pilot hole is then created in the anterolateral greater tuberosity, and the two anterolateral suture limbs are loaded into the pushin anchor outside the cannula. The anchor is then placed through this cannula, into bone, taking care not to excessively tension the graft. The posterior lateral suture limbs are then brought back into the anterolateral cannula. Using the same technique but with internal rotation of the arm, the posterior lateral anchor can be placed into the posterior lateral greater tuberosity, completVignette ing the augmentation (Figs. 22-13 and 22-14).

c POSTOPERATIVE MANAGEMENT • Begin gentle elbow, wrist, and hand mobility exercises immediately. • Begin gentle pendulum shoulder motion exercises twice a day 48 hours postoperatively. • Wear an UltraSling in public and in any “unpredictable situation” for 6 weeks. • Begin formal physical therapy at 6 weeks. Rotator cuff strengthening exercises are allowed between 3 and 4 months postoperatively.

dermal allograft augmentation in five patients. They had three intact repairs, one partial tear, and one complete re-tear at 1 year, with no adverse events. Some authors reported on their experience with a synthetic scaffold (Biomerix RCR Patch, Biomerix, Fremont, CA) in 10 patients. Nine patients had intact repair, and one had a re-tear on MRI at 1  year. Their patients had significant overall improvements in University of California at Los Angeles (UCLA), American Shoulder and Elbow Surgeons, and Simple Shoulder Test (SST) scores. They reported no adverse events. Barber et al. published a prospective, randomized study on rotator cuff augmentation. They conducted a multicenter study of patients undergoing arthroscopic repair of two-tendon rotator cuff tears measuring greater than 3 cm. Twenty-two patients were randomized to arthroscopic single-row rotator cuff repair coupled with human dermal allograft augmentation (group 1), and 20 patients were included in the group without augmentation (group 2). At 24-month follow-up, Constant scores and ASES scores showed significant differences between the groups in favor of augmentation. Gadolinium-enhanced MRI showed intact repairs ­ in 85% of group 1 augmented patients and 40% of group 2 ­nonaugmented patients. No adverse events RCR Alt GJA were reported (Fig. 22-15).

c POTENTIAL COMPLICATIONS

c RESULTS There are few studies to date that evaluate outcomes associated with rotator cuff repair augmentation. Some authors reported on their preliminary experience using human

Complications for this procedure are extremely rare. The average operative time is increased by approximately 30  minutes when compared with a standard large rotator cuff repair surgery, putting patients at risk for transient

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Chapter 22

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Rotator Cuff Repair with Augmentation 331

FIGURE 22-13.  The graft is ­secured

to the lateral greater tuberosity with two push-in knotless anchors, completing the augmentation.

neuropraxia. As of the time of this publication, we have had no cases of major complication related to surgical time, arm traction, infection, or rejection.

c PEARLS: KEY THOUGHTS FOR ENSURING GOOD SURGICAL OUTCOME

Visual Analog Scale (VAS) pain scores are much more likely to have little or no pain postoperatively. 2. Patient expectation management: We spend a significant amount of time with preoperative counseling for these patients. They need to be carefully consented regarding

1. Patient selection: As with any patient with rotator cuff pathology, we have found that preoperative active range of motion is the best predictor of postoperative subjective success. Similarly, patients with lower preoperative

FIGURE 22-14.  Arthroscopic

appearance of the completed graft augmentation of a large rotator cuff repair.

FIGURE 22-15. MRI arthrogram scan 1 year postoperatively after r­ evision rotator cuff repair with graft augmentation. The tendon is healed to bone, with normal tendon width across the greater tuberosity.

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332 SCOI Shoulder Arthroscopy

the use of the graft, the extended time period involved in recovery after a large rotator cuff repair (up to 2 years of strength improvements), and the high nonhealing rates associated with surgery on “high-risk” rotator cuff tears. 3. Surgical visualization: Take the necessary time to properly debride tissue and obtain hemostasis. As the case progresses, clear visualization can be expected to become more difficult. 4. Portal placement: The anterolateral portal must be accurately placed such that it is in the correct position for graft entry as well as for placement of both the lateral anchors. 5. Stitching: In order to get the graft to spread out evenly, stitching within the shoulder must be very accurate, and must closely reapproximate the positions of the STIK sutures on the graft. When in doubt, it is better to overestimate the distance between sutures than to underestimate, as underestimation will lead to a loose, dysfunctional graft once the sutures are tied. 6. “STAY ANTERIOR”: Always pay close attention when passing the STIK sutures. Always keep the shuttling suture and the grasper anterior to any other sutures in the cannula.

Suggested Readings

Frequently Asked Questions

Boileau P, Brassart N, Watkinson DJ, et al. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am 2005;87:1229–1240.

1. How many sutures are enough? We prefer at least six if not more circumferential sutures. Most of these grafts are at least 3 cm in diameter, and while they do hold a stitch very well, fixation of the graft with less than six sutures both decreases its holding strength and increases the likelihood of creating a poorly tensioned “dog-ear” in the construct. 2. Can’t you just use suture limbs from the tendon repair to secure the graft? Yes, you can, and in some cases we do (see Case Exam­ ple). However, if a suture has already been tied to secure the native tendon, using that same stitch to stabilize the graft fixes the graft to the top of the knot, not the tendon itself. Also, we do not want to risk compromising the native rotator cuff repair by waiting and attempting to tie both cuff and graft down together. We prefer to complete the native repair first and then move on to the augmentation. 3. What if you cannot get a full tendon repair? We recommend repairing all native tendons as much as possible. At that point, the augmentation graft can be placed over the top, covering a residual defect. At the time of this publication, the US Food and Drug Administration (FDA) has approved the use of this product to span residual defects of up to 1 cm2.

Aurora A, McCarron JA, van den Bogert AJ, et al. The biomechanical role of scaffolds in augmented rotator cuff tendon repairs. J Shoulder Elbow Surg. 2012;21(8):1064–71. Barber FA, Aziz-Jacobo J. Biomechanical testing of commercially available soft-tissue augmentation materials. Arthroscopy 2009;25(11):1233–1239. Epub October 2, 2009. Barber FA, Burns JP, Deutsch A, et al. A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair. Arthroscopy 2012;28(1):8–15. Barber FA, Herbert MA, Boothby MH. Ultimate tensile failure loads of a human dermal allograft rotator cuff augmentation. Arthroscopy 2008;24(1):20–24. Barber FA, Herbert MA, Coons DA. Tendon augmentation grafts: biomechanical failure loads and failure patterns. Arthroscopy 2006;22(5):534–538. Bishop J, Klepps S, Lo IK, et al. Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study. J Shoulder Elbow Surg 2006;15:290–299.

Bond JL, Dopirak RM, Higgins J, et al. Arthroscopic replacement of massive, irreparable rotator cuff tears using a GraftJacket allograft: technique and preliminary results. Arthroscopy 2008;24(4):403–409.e1. Burkhead WZ, Schiffern SC, Krishnan SG. Use of GraftJacket as an augmentation for massive rotator cuff tears. Semin Arthroplasty 2007;18:11–18. doi:10.1053/j.sart.2006.11.017. Chaudhury S, Holland C, Thompson MS, et al. Tensile and shear mechanical properties of rotator cuff repair patches. J Shoulder Elbow Surg 2012;21(9):1168–1176. Cho NS, Rhee YG. The factors affecting the clinical outcome and integrity of arthroscopically repaired rotator cuff tears of the shoulder. Clin Orthop Surg 2009;1:96–104. Cole BJ, McCarty LP III, Kang RW, et al. Arthroscopic rotator cuff repair: prospective functional outcome and repair integrity at minimum 2-year follow-up. J Shoulder Elbow Surg 2007;16: 579–585. Coons DA, Alan Barber F. Tendon graft substitutes-rotator cuff patches. Sports Med Arthrosc 2006;14(3):185–190. Davidson PA, Rivenburgh DW. Rotator cuff repair tension as a determinant of functional outcome. J Shoulder Elbow Surg 2000;6:502–506.

c CASE EXAMPLES

Derwin KA, Baker AR, Spragg RK, et al. Commercial extracellular matrix scaffolds for rotator cuff tendon repair: biomechanical, biochemical, and cellular properties. J Bone Joint Surg Am 2006;88(12):2665–2672.

Dr. Snyder gives a short clinical vignette summarizing an alternative technique for augmenting a rotator cuff revision repair; including history, imaging, video technique and postoperative plan.

Encalada-Diaz I, Cole BJ, MacGillivray JD, et al. Rotator cuff repair augmentation using a novel polycarbonate polyurethane patch: preliminary results at 12 months’ follow-up. J Shoulder Elbow Surg 2011;20:788–794. Galatz LM, Ball CM, Teefey SA, et al. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am 2004;86:219–224.

RCR w Augment

RCR Alt GJA

Montage

Gladstone JN, Bishop JY, Lo IK, et al. Fatty infiltration and ­atrophy of the rotator cuff do not improve after rotator cuff

(c) 2015 Wolters Kluwer. All Rights Reserved.

Chapter 22

repair and correlate with poor functional outcome. Am J Sports Med 2007;5:719–728. Goutallier D, Postel JM, Van Driessche S, et al. Tension-free cuff repairs with excision of macroscopic tendon lesions and muscular advancement: results in a prospective series with limited fatty muscular degeneration. J Shoulder Elbow Surg 2006;15:164–172. Gulotta LV, Nho SJ, Dodson CC, et al. Prospective evaluation of arthroscopic rotator cuff repairs at 5 years, part II: prognostic factors for clinical and radiographic outcomes. J Shoulder Elbow Surg 2011;20:941–946. Ide J, Kikukawa K, Hirose J, et al. Reconstruction of large rotatorcuff tears with acellular dermal matrix grafts in rats. J Shoulder Elbow Surg 2009;18(2):288–295. Keener JD, Wei AS, Kim HM, et al. Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome. J Bone Joint Surg Am 2010;92(3):590–598. Kovacevic D, Rodeo SA. Biological augmentation of rotator cuff tendon repair. Clin Orthop Relat Res 2008;466(3):622–633. Epub February 10, 2008.

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Nicholson GP, Breur GJ, Van Sickle D, et al. Evaluation of a crosslinked acellular porcine dermal patch for rotator cuff repair augmentation in an ovine model. J Shoulder Elbow Surg 2007;16(5) (Suppl):S184–S190. Epub June 15, 2007. Oh JH, Kim SH, Ji HM, et al. Prognostic factors affecting a­ natomic outcome of rotator cuff repair and correlation with functional ­outcome. Arthroscopy 2009;1:30–39. Rodeo SA. Biologic augmentation of rotator cuff tendon repair. J Shoulder Elbow Surg 2007;16(5)(Suppl):S191–S197. Epub June 15, 2007. Rotini R, Marinelli A, Guerra E, et al. Human dermal matrix scaffold augmentation for large and massive rotator cuff repairs: preliminary clinical and MRI results at 1-year follow-up. Musculoskelet Surg 2011;95(Suppl 1):S13–S23. Snyder SJ, Arnoczky SP, Bond JL, et al. Histologic evaluation of a biopsy specimen obtained 3 months after rotator cuff augmentation with GraftJacket Matrix. Arthroscopy 2009;25(3):329–333. Epub July 24, 2008.

McCarron JA, Milks RA, Mesiha M, et al. Reinforced fascia patch limits cyclic gapping of rotator cuff repairs in a human cadaveric model. J Shoulder Elbow Surg 2012;21(12):1680–1686.

Soler JA, Gidwani S, Curtis MJ. Early complications from the use of porcine dermal collagen implants (Permacol) as bridging constructs in the repair of massive rotator cuff tears. A report of 4 cases. Acta Orthop Belg 2007;73(4):432–436.

Montgomery SR, Petrigliano FA, Gamradt SC. Biologic augmentation of rotator cuff repair. Curr Rev Musculoskelet Med 2011;4:221–230.

Tashjian RZ, Hollins AM, Kim HM, et al. Factors affecting healing rates after arthroscopic double-row rotator cuff repair. Am J Sports Med 2010;12:2435–2442.

Nho SJ, Brown BS, Lyman S, et al. Prospective analysis of arthroscopic rotator cuff repair: prognostic factors affecting clinical and ultrasound outcome. J Shoulder Elbow Surg 2009;18:13–20.

Wong I, Burns J, Snyder S. Arthroscopic GraftJacket repair of rotator cuff tears. J Shoulder Elbow Surg 2010;19(2)(Suppl): 104–109.

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23

Arthroscopic Technique for Reconstructing a ­Massive Nonrepairable ­Rotator Cuff Defect ­Using ­Acellular ­Human Dermal Matrix Allograft c INTRODUCTION Despite the many new developments in rotator cuff repair discussed in previous chapters, successful management of the symptomatic chronic, massive, irreparable rotator cuff tear continues to frustrate shoulder surgeons (1–3). While the spectrum of rotator cuff disease is far from being fully understood, we now know that patient age, chronicity of the lesion, smoking, and severe muscle and tendon degeneration are proven confounding factors that negatively influence healing potential (4). It is also understood that revision of a previously failed rotator cuff repair is fraught with problems, especially when there is a re-tear near the muscle–tendon junction (a so-called type 2 failure), now more frequently being seen after some types of “double-row” or high-tension rotator cuff repairs (5) (Fig. 23-1). Some patients with irreparable tears are minimally symptomatic, and can be treated nonoperatively with physical therapy or by a simple arthroscopic debridement with ­biceps tenodesis or tenotomy (6,7). However, there remain a ­ significant number of problematic patients for whom conservative treatment is unsatisfactory. For older patients,

especially those with arthritis, reverse total shoulder arthroplasty can be an excellent option (8,9). In a physiologically younger, active, and thus higher-demand patient, these procedures would mandate unwanted restrictions and would limit physically demanding employment as well as many recreational activities. Additionally, the younger patient’s life expectancy would exceed the wear characteristics of the implant, and salvage procedures after reverse total shoulder arthroplasty are not routinely successful. Some younger patients may benefit from a latissimus dorsi muscle transfer, although the published results of this very invasive operation are often not favorable even when performed by experienced surgeons (9,10,11). The transfer of a normal tendon to a “nonanatomical” location may improve external rotation but seldom shoulder elevation. Unfortunately, the outcome and unsatisfactory ­healing rate that often follows the traditional repair of large, chronic, and degenerative rotator cuff tendons has impelled the use of supplemental surgical techniques involving biologic scaffolds and other bioactive agents intended to enhance or ­replace the traditional repairs. Besides the major ­requirement that a successful graft must function as a matrix scaffold 335

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336 SCOI Shoulder Arthroscopy

completely replace the failed rotator cuff. These new biologic materials are called extracellular matrix (ECM) grafts. There are numerous classes of biologic matrices available, including dermal allografts, dermal xenografts, resorbable and nonresorbable fabrics, and numerous other collagen and man-made products. Each of these products has unique properties that distinguish it from others. The particular characteristics of a graft are determined by the species or source of the material, the strength, and the biologic activity. The surgeon must understand these unique features before ever using them in a patient. The following list highlights the important considerations that we use at the Southern California Orthopedic Institute (SCOI) when choosing a biologic rotator cuff graft material for bridging a nonrepairable rotator cuff defect.

FIGURE 23-1.  A typical Type 2 failure following a double-row repair of a rotator cuff tendon has a segment of tendon healed and remaining on the tuberosity and a small portion of residual tendon retracted medially with the muscle. that bridges the cuff defect, an ideal graft should also enhance cellular recruitment and adherence as well as facilitate tendon regrowth, leading to the development of “cufflike” tissue, replacing and functioning like a normal rotator cuff tendon. A successful biologic “patch” must possess a sustainable blood supply arising from the cancellous bone of the humeral tuberosity, and it must have a firm attachment to the residual rotator cuff tissue on all sides. In addition, the “graft” must regenerate a robust bony attachment or “footprint” on the greater tuberosity by fusing the cuff/graft tissues to bone with a fibrocartilage enthesis that will diffuse the stress of tendon rotation and tension at the attachment. The healed graft must possess the capacity to continue to regenerate and function as a “biologic hood,” maintaining the humeral head in the glenoid by restricting proximal subluxation and by cushioning the contact of the humerus on the acromion. In addition, if a graft is successful in closing the cuff defect by linking anterior-to-posterior and ­medial-to-lateral tissues, it should improve the biomechanical force couple by providing a more favorable functional rotational vector for the deltoid muscle (12–14). The obvious solution to this fundamental quandary is to reinforce the severely damaged cuff tendon using a matrix grafting material; when it is not possible to close the defect entirely, then it should be replaced using a graft to act as a bridge connecting the stump of the cuff to bone. In the past, graft materials—both synthetic and biologic—have been utilized, but none of these materials has proven consistently reliable and successful. Although new synthetic materials are now available, orthopedists are understandably cautious when presented with any sort of unproven graft material to replace this important tendon (15). Currently, there is a resurgence of interest among shoulder scientists to discover safe biologic methods to

1. A negligible risk of disease transfer or inflammatory ­rejection, and have all donor cells removed. 2. A robust initial strength, rendering it strong enough to preclude suture cutout. 3. A moderately elastic nature to avoid stress overload at the suture–graft interfaces. 4. Favorable handling characteristics, preferably soft and pliable, and thus suitable for arthroscopic insertion via a cannula. 5. An inherent biologic quality that will stimulate rapid repopulation with appropriate patient’s mesenchymal stem cells. 6. Preserved vascular access channels and cell-binding sites. 7. A minimally cross-linked collagen structure that will encourage invasculation with cell ingrowth and avoid scar tissue encapsulation. 8. Natural growth factors within the graft material. 9. Availability as a cryopreserved or ready-to-use product possessing a favorable shelf life, facilitating local storage and availability. 10. A reasonable price point to make it available for widespread use. 11. Encouraging animal and laboratory data, especially when tested in primates (16,17). 12. A favorable human clinical history. Modern tissue banks offer safe, reliable, and readily available allograft tissue with proven success in reconstruction of many areas of the body. There are abundant animal studies supporting the concept that certain acellular dermal graft materials are successful for restoring deficiencies in a variety of body tissues, including skin, bladder, blood vessels, ligaments, and tendons. Shoulder surgeons are now comfortable exploring the potential applications of allografts for replacing damaged rotator cuff tissue. Our graft of choice in symptomatic patients with chronic nonrepairable rotator cuff defects over the past 9 years is a human acellular dermal matrix allograft, GraftJacket (Wright Medical Technology, Memphis, TN) (Figs. 23-2 and 23-3). The preimplanted GraftJacket acellular human dermal matrix is free from cells, but rich in collagen, elastin, and preserved blood vessel channels. Reported human clinical studies document the effective use of acellular human dermal allograft (AHDA), both to augment and replace severely deficient rotator cuff tissue, fulfilling the goals of improved shoulder function and

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FIGURE 23-2.  GraftJacket is a cryopreserved AHDA that is prepared by removing the epidermis and cellular components but preserving the collagen, elastin, fibronectin, proteoglycans, and blood vessel channels.

FIGURE 23-3.  The preimplanted GraftJacket acellular human dermal matrix is free from cells but rich in collagen, elastin, and preserved blood vessel

channels.

lower pain scores. In addition, there are several published case reports describing postoperative human biopsies that document robust cellular and vascular ingrowth, tendon-like collagen fiber regeneration, as well as the formation of a fibrocartilage enthesis in patients who have undergone human acellular dermal allografts (17–19) (Fig. 23-4).

Rotator cuff reconstruction with a biologic matrix can now be successfully performed in an outpatient surgical center using arthroscopic techniques, with minimal morbidity to surrounding tissue. Human-derived ECM grafts are classified as human tissue for transplantation (FDA-21 CFR, part 1270), and thus require no FDA clearance for use in humans. Devices such as the GraftJacket are being used clinically both to augment rotator cuff repairs and as interpositional or bridging grafts. When GraftJacket is used to augment a deficient tendon or bridge a cuff defect less than 1 cm, it is “on-label.” When GraftJacket is used to bridge a gap or replace a cuff defect greater than 1 cm, it is “off-label” at the time of this writing. With the growing number of successful human bridging cases being reported in the literature as well as the abundant successful animal studies, we anticipate that the FDA labeling will change in the near future.

c PATIENT SELECTION FIGURE 23-4.  This

is a human biopsy of GraftJacket dermal allograft tissue taken at 3 months postoperatively showing complete infiltration of the matrix material with blood vessels and fibroblasts, and with collagen arranged in an organized linear pattern resembling normal tendon. Movat’s pentachrome stain 50×.

The indications and contraindications for bridging massive rotator cuff defects are still evolving. As a “salvage” procedure, that is when there is a massive retracted cuff defect with no remaining tissue available to perform a primary repair, contraindications include patients with significant glenohumeral arthritis, active infection, immunologic

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compromise, severe stiffness, complete loss of the medial rotator cuff tendon stump, incompetent deltoid function, and medical problems that would pose a substantial risk during a 3-hour operation. Fatty infiltration or rotator cuff muscle atrophy, tear size, chronicity, and age are not contraindications as they have been associated with successful outcomes in our cases. “Ideal” patients for arthroscopic rotator cuff replacement are young patients with minimal chondromalacia, mild or moderate pain, active forward flexion greater than 130 degrees, some active external rotation power, and no prior failed surgeries. Patients with early chondromalacia, severe pain, poor motion (but not stiffness), and several prior surgeries are still candidates for surgery and can be expected to improve, but their outcomes will likely be inferior to those who meet the “ideal” criteria.

c IMAGING All patients who are candidates for AHDA reconstruction of a nonrepairable rotator cuff defect should have recent good-quality x-rays. The preoperative series should include an anterior-posterior (AP) view, axillary view, lateral acromial or “Y” view, and a Zanca acromioclavicular (AC) joint view. These are all important to assess the shape and thickness of the acromial arch, the condition of the joint surfaces and joint space, the status of the AC joint, the position of the humeral head in relation to the acromion, as well as the presence and type of any residual suture anchors in the greater tuberosity (Fig. 23-5). If metal suture anchors are present, it is beneficial to know the type of anchor and to have an appropriate retrieval screwdriver available to use if needed. Magnetic resonance imaging (MRI) scans are mandatory for preoperative evaluation. It is essential for surgical planning to assess the bone of the greater tuberosity and be

FIGURE 23-5.  Preoperative x-rays are important to document the status of the joint, including any acromial or AC joint spurs, the position of the humeral head relative to the acromion, any arthritis or deficiencies in the bones, and any residual anchors.

FIGURE 23-6.  The preoperative MRI scan is essential to evaluate the status of the bone of the greater tuberosity for cysts and defects that may require bone grafting.

aware of any cysts or anchor defects that may require attention such as bone grafting (Fig. 23-6). If the rotator cuff stump is retracted medial to the glenoid, it is necessary to ensure that there is adequate tendon to attach the sutures for the graft fixation (Fig. 23-7). Also, it is important for surgical planning and prognostication to be aware of the status of the subscapularis and biceps tendons as well as the quality and state of rotator cuff muscle tissue (Fig. 23-8). In addition, MRI is useful to document potential articular surface bony defects such as avascular necrosis in the humeral head that could potentially result in surgical failure despite achieving a successful graft (Fig. 23-9).

FIGURE 23-7.  In this case, the residual stump of the rotator cuff is so deficient that there is no tissue available to attach the medial end of the allograft matrix.

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FIGURE 23-8.  The MRI is important to evaluate the subscapularis and biceps tendons.

pulling out of the graft when bringing it into the shoulder (Fig. 23-10). 2. Make a “knotted suture measuring device” by tying a STIK loop on one end of a #0 braided suture and then forming simple half-hitch knots along the suture at 1-cm intervals for 5 cm, beginning 1 cm from the loop end. Color every other knot with a surgical marker. Load the nonloop end of the suture into a singleeye knot pusher, and pull it up to the STIK loop on the end. The loop end of the suture will be passed into the shoulder with the knot pusher so that it can be grasped with a small clamp via another portal. The knotted suture device can be laid along the edges of the cuff defect and measured by counting the knots (Fig. 23-11). 3. Hydrate or otherwise prepare the graft in room-­ temperature sterile saline if needed.

Shoulder Arthroscopic Evaluation, Debridement, Decompression, and Preparation (The scope position is changed to any appropriate portal.)

FIGURE 23-9.  A preoperative MRI will document bony abnormalities such as avascular necrosis.

c SCOI ARTHROSCOPIC SURGICAL TECHNIQUE FOR PERFORMING AN ACELLULAR HUMAN DERMAL ALLOGRAFT TO REPLACE A NONREPAIRABLE ROTATOR CUFF DEFECT Preoperative Preparation (Back Table) 1. Tie 12 short-tailed interference knot (STIK) sutures using three different colors of #2 braided polyester suture. Form the STIKs by wrapping a suture once around a 2-mm metal rod and tying a bulky knot with a loop on one end. Always test the security of the knot by pulling firmly on the free end of the STIK while the loop is still on the post. This loop will facilitate grasping of the sutures when retrieving it for tying. The bulky “interference” knot below the loop will prevent the suture from

4. Begin by creating standard posterior mid-glenoid portal (PMGP) and anterior mid-glenoid portal (AMGP), and place a 7-mm docking cannula in each one (­Dry-Doc 2  × 95 mm, Conmed/Linvatec, Largo, FL). These “docking” cannulas will remain in these portals for the entire case, and the stitching and knot-tying tools and the arthroscope can be moved between them, without the need to remove the cannulas. 5. Perform a 15-point evaluation of the shoulder, and document the condition of the cartilage surface, labrum, biceps, subscapularis, synovium, and rotator cuff. 6. Prepare the shoulder joint by debriding the degenerative cuff edges and thickened bursal scar. Repair any significant subscapularis or labral tissues as needed. Mobilize the medial stump of the rotator cuff by carefully releasing the scar and capsule just above the glenoid. 7. Prepare the bursal space by smoothing the underside of the acromion and AC joint if needed. Remove any suture anchors that are obstructing the bone needed for the graft attachment, usually the area 3 cm lateral to the articular cartilage edge. If there are cysts or large bony defects that will likely compromise the fixation stability of the new anchors, they should be filled with a suitable bone graft material. Debride all soft tissue and lightly decorticate the greater tuberosity, including the area of the biceps groove. This will create a better surface for regrowth of the footprint and for healing of a biceps tenodesis. Create the midlateral subacromial portal (MLSAP) carefully. Use a spinal needle to select a location 3 to 4 cm lateral to the midpoint of the cuff defect (not in the mid-acromial position as that position may not be centered on the cuff tear). Insert an 8-mm docking cannula in this portal (8 × 75 mm “red” Dry-Doc cannula, Conmed/Linvatec, Largo, FL). If the cuff defect is noted to be very large, that is, greater than 3.5 cm, then

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FIGURE 23-10.  Twelve STIKs are tied using #2 braided polyester suture over a 2-mm metal rod. a 10-mm cannula with an external rubber diaphragm is recommended (Smith and Nephew, ­Andover, MA). It is very helpful to create a suprascapular notch portal to store the free ends of the medial (white) sutures to facilitate seating the graft. This is best performed by first inserting a spinal needle at the medial edge of the suprascapular notch just posterior to the AC joint. ­Locate the needle by clearing the soft tissue in that area with a shaver. Make a stab incision just large enough to insert a ring grasping forceps to retrieve each free end of the medial STIKs as they pass through the top of the cuff stump. ­Retrieving and storing the sutures through the suprascapular notch portal facilitates pulling the graft into the shoulder and lessens the chance of twisting sutures (Fig. 23-12).

FIGURE 23-11.  The knotted suture measuring device is created by tying

a STIK loop on one end and multiple simple half-hitch knots at 1-cm intervals along a strand of #0 braided suture.

Inserting the First Suture Anchor (The scope is placed in the MLSAP at the 50-yard line of the tear, or, if desired, it may be placed in a posterior-lateral

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B

FIGURE 23-12.  A, B: The suprascapular notch portal is useful to store the free ends of the medial STIKs. portal 2 cm posterior to the MLSAP without using an ­operating cannula.) 8. Use a spinal needle as a guide to choose a spot for the first suture anchor. The ideal position is a few millimeters anterior to the posterior edge of the cuff stump and 5 mm lateral to the edge of the articular cartilage. Before each anchor is inserted, use a small 2-mm bone punch to create a starter hole. Also ­create five to nine

“bone marrow vents” by puncturing the exposed bone of the lateral tuberosity (away from the anchor sites). Always direct the punch used for the vents vertically down the humerus and thus away from the subchondral bone area where the anchors will be seated (Fig. 23-13). 9. Insert the first triple-loaded suture anchor into the posterior pilot hole. Angle it in a medial direction, passing 45  degrees under the subchondral bone, the so-called

FIGURE 23-13.  A,

B: The 2-mm bone punch is used to create five to nine “bone marrow vents” in the prepared tuberosity lateral from the ­anchor fixation sites.

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342 SCOI Shoulder Arthroscopy

“tent-peg” angle. The eyelet of the anchor is seated 2 mm below the bone surface, and is always aligned in a medial-to-lateral direction so that the sutures exit toward the edge of the medial cuff stump. The second anchor, the anteriormost one, can either be inserted at this time or following the measurement of the defect (Fig. 23-14). 10. Perform a “partial cuff repair” by fixing as much of the remaining posterior cuff to the tuberosity as possible. Pass the medial limb of the posteriormost suture from the posterior anchor through the edge of the posterior cuff near the attachment site on the bone. Do not attempt to advance the tendon anteriorly under tension. The goal of this stitch is to secure a posterior “framework” for attachment of the graft. If a suture shuttle technique is used, first retrieve the medial limb of the posteriormost suture into the AMGP. Pass the shuttle device through the cuff stump, using a crescent-shaped stitching needle via the PMG cannula. Retrieve the Shuttle into the AMG cannula, load the suture, and carry it back through the cuff and out of the back. Tie the sutures using a sliding-locking knot. Clamp the remaining sutures next to the skin to hold them snug (Fig. 23-15).

B

FIGURE 23-13.  (continued)

FIGURE 23-14. A,

B: The first triple-loaded suture anchor is inserted percutaneously near the posterior attachment of the native rotator cuff.

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Measuring the Defect in the Rotator Cuff 11. Insert the “knotted suture” measuring device using the single-eye knot pusher via the PMG cannula. Grasp the loop end of the suture with a small clamp inserted through the AMG cannula and maneuver it to the area of the biceps groove. Place the tip of the knot pusher near the posterior suture anchor. Count the knots between the loop and the tip of the knot pusher. Measure all four sides of the cuff defect. On the lateral edge, measure from 5 mm posterior to the posterior anchor to the area of the biceps tendon or biceps groove. The measurement of the medial edge should likewise ­allow a 5-mm overlap. A surgical technician records the measurements and creates a pattern on a towel using a marking pen (Fig. 23-16).

B

FIGURE 23-14.  (continued)

A

FIGURE 23-15.  A, B: Perform a partial cuff repair by passing the poste-

riormost suture from the posterior anchor through the adjacent rotator cuff and tie it together.

B

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344 SCOI Shoulder Arthroscopy

A

FIGURE 23-16.  A, B: The knotted suture measuring device is used to measure the rotator cuff defect.

Preparing the Graft (on the Back Table) 12. A surgical assistant prepares the graft on the back table. Place the moist graft on the pattern that was created on the towel, and press it carefully to transfer the pattern to the graft. Cut the graft along the edge of the pattern, and replace the remaining portion in the saline bath.

B

Determine the “shiny” or epidermal side of the graft that will be the upper surface. Mark dots on the graft to indicate the locations for the STIK sutures. The dots should be 5 mm from the edge of the graft and spaced 8 mm apart on the posterior, medial, and anterior borders. Also, place a dot at the anterior- and posterior-lateral corners to mark the insertion site of the middle suture from the posterior and anterior anchors. Draw a 1-cm centerline in the middle of the lateral edge.

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Insert a STIK suture into each dot using a Keith needle so that the STIK loop knot is on the upper side. No STIK is placed in the two lateralmost spots. Use white sutures for the medial STIKs, and color the knot and free end of every other medial suture with the skin marker. This will identify them during graft passage and suture retrieval for tying. Pass alternating dark-green and light-green STIK sutures along the medial and lateral borders. Always keep the graft hydrated by dousing it with saline during the preparation (Fig. 23-17).

Inserting the Anterior Anchor and Performing a Biceps Tenodesis Using an “Italian Loop” Stitch

any substantial rotator interval tissue and through the center of the biceps tendon at the level of the anchor. Send the Shuttle and retrieve it with a grasping clamp into the PMG cannula. Load the Shuttle, and carry the suture back through the biceps and into the AMG cannula. Retrieve the same suture again into the PMG cannula. Pass the needle, and Shuttle again through the rotator interval and around the biceps tendon, a few millimeters away from the initial pass. Send the Shuttle again, retrieve it, and load the suture outside the PMG cannula. Pull the Shuttle out of the AMG cannula to complete the “Italian loop” stitch. Tie the suture using a nonsliding “Revo” knot. Secure the remaining sutures by placing a clamp snugly adjacent to the skin (Fig. 23-18).

13. Use the spinal needle as a guide for the anterior anchor. Attaching the Graft to the Posterior Insert it just posterior to the biceps tendon, 5 mm lateral and Medial Cuff to the articular cartilage. Retrieve the most anterior-­ (Scope in the AMG cannula) medial suture into the PMG cannula. Pass an appropriately curved suture needle via the AMG cannula through 14. Wrap a surgical towel around the arm 5 cm lateral to the MLSA cannula, and secure it with a towel clamp. Place the graft on the moistened towel, and orient it so that it is rotated 45 degrees posteriorly. Secure the tails of the STIK sutures by clamping them with an Alice clamp to prevent the graft from falling or twisting. (It is imperative to ensure that when the STIK sutures are retrieved, they always pass between the two suture anchors and the anchor sutures, which are snugly secured with clamps next to the skin, the so-called “suture stack.” Each successive suture must pass parallel to the previous one and anterior to it. If the sutures do cross or A are not parallel, they will cause the graft to twist when it is pulled into the shoulder, creating a very difficult situation when tying the sutures to secure the graft.) 15. Retrieve the medial limb of the center suture of the posterior anchor into the MLSA cannula with a crochet hook. Be certain that the suture passes medial to the “­suture stack” and between the remaining sutures in the anchors. Pass the suture through the graft from bottom to top at the target spot on the posterior-lateral corner with a Keith needle. Tie a STIK on the top side of the graft, and pull the other end to take up the slack so that the edge of the graft is 10 cm away from the MLSA cannula. Hold the sutures to the moist towel using an Alice clamp. Clamp the remaining three sutures from the posterior anchor with a Kelly clamp adjacent to the skin to hold them taut (Fig. 23-19). 16. Choose the free end of the most lateral-posterior loop STIK, and clamp it in the posterior Alice clamp in preparation for passing. This is referred to as “staging B the suture.” 17. Use a crescent-shaped suture hook to pass a Shuttle through a healthy FIGURE 23-17.  A, B: The graft is prepared on the back table by cutting bite of the posterior cuff remit to size and inserting the STIK sutures around the edges. The medial STIKs are all white sutures and every other one is marked with a purple skin marker. nant 8 mm medial to the posterior

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A

FIGURE 23-18.  A, B: Pass the anteriormost suture from

the anterior anchor through the biceps tendon twice to perform an “Italian loop” biceps tenodesis.

B

suture anchor. Retrieve it anterior to the previously passed anchor suture and between the “suture stacks” into the MLSA cannula. Load the Shuttle, and carry it back through the cuff and into the PMG cannula (Fig. 23-20). 18. Continue passing the remaining STIKs along the posterior edge of the cuff defect, placing each stitch 8 mm more medial than the previous one. Usually the crescent-shaped suture hook is appropriate for passing all posterior STIK sutures.

Alternative Stitching Method— Direct Suture Passing (Scope in appropriate portal for best viewing) 19. Some surgeons prefer suturing with the “direct pass” method via the lateral portal. This technique works well as long as the sutures are passed sequentially from posterior to medial and then anterior, and great care is taken to avoid crossing the sutures. Load the direct pass

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FIGURE 23-19.  The middle limb of the medial suture from the posterior anchor is retrieved into the lateral cannula and passed through the posterior-lateral corner of the graft. needle with the free end of the STIK outside the MLSA cannula, and pass it into the joint with the suturing ­device. Drive the needle through the cuff remnant from bottom to top, and retrieve the suture out of the top with a grasper in the PMG cannula. 20. Continue suturing along the medial edge of the cuff stump using the appropriate suture needle, usually a 45-degree right or left hook and sometimes using a ­­60- or 90-degree hook needle. Often, the anteriormost corner stitch from the medial row is best reached from the anterior cannula. Four or five STIK sutures are used for the medial side (Fig. 23-21).

Attaching the Graft to the Anterior Cuff and Biceps Tendon (Scope in PMGP or accessory posterior-lateral portal) 21. Stitch the anterior edge of the defect to any remaining rotator cuff, coracohumeral ligament, or rotator interval tissue that is available. Sometimes, if there is no anterior tissue, one or two stitches may need to be passed through the subscapularis tendon. Use the same steps as described for the posterior stitches, but progress from medial to lateral with the curved suture hook inserted

through the AMG cannula. Be certain that the suture hook passes “anterior” to the anterior “suture stack” and the Shuttle is retrieved posterior to it. Pass the first STIK through the rotator interval tissue 8 mm lateral from the anterior-medial STIK, and retrieve it out of the MLSA cannula. Again, be very careful not to cross any sutures, and always retrieve the Shuttle anterior to the other previously passed sutures. Do not pass the most medialanterior-medial suture through the biceps, because there is usually adequate interval tissue available (Fig. 23-22). 22. Continue progressing along the anterior edge of the defect, incorporating the rotator interval tissue (and the biceps, if it is present and needed) in the remaining stitches. Leave the free ends of the anterior STIKs in the AMG cannula. 23. Retrieve the medial end of the middle suture from the anterior anchor into the MLSA cannula. Be certain that it passes medial to the other sutures in that anchor to avoid twisting. Pass this suture from bottom to top through the graft at the anteriorlateral corner target spot, and tie a STIK on the top. Pull up the slack and clamp the ends outside the skin.

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A

FIGURE 23-20.  A, B: Pass the crescent-shaped suture

hook through the posterior cuff 8 mm medial from the previous knot, and retrieve the Shuttle-Relay via the lateral portal when it is loaded with a STIK suture.

B

Delivering the Graft into the Shoulder (Scope removed from the shoulder) 24. Orient the graft so that the medial edge is directed toward the cannula. A serious problem will occur if some of the sutures are slack and others tight when the graft is pulled into the MLSA cannula. This can result

if a loop of slack suture of a STIK wraps around the knotted end of another STIK. Avoid this by pulling on the ends of the medial STIK sutures (white and white/ purple sutures exiting the suprascapular notch portal) and taking up all slack by pulling on them enough to deliver the graft to the mouth of the MLSAP. Next, pull on the free ends of all the other STIK sutures

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A

FIGURE 23-21. A, B: The medial sutures are passed through the rotator cuff stump with a curved suture hook, and they are retrieved and stored in the suprascapular notch portal.

B

exiting the AMGP and PMGP, as well as the two anchored sutures, just enough to take up any slack and make them all equal tension. Roll the graft so that the knots are inside. Pull the medial (white) suture tails to lead the graft into the cannula. Alternate pulling on the medial STIKs for a centimeter and take up any slack of the other sutures. This stepwise method will prevent any suture loops forming that can catch on the STIKs, causing the graft to seat ­improperly (Fig. 23-23).

Tying the STIK Sutures (Scope in MLSA or AMG cannula) 25. Retrieve all sutures located in the PMG cannula into the AMG cannula except the last lateral STIK. R ­ etrieve the knotted end of the most posteriorlateral STIK into the PMG cannula and tie the sutures using a slidinglocking knot. Use the unknotted end of the STIK as the post. Alternatively, we often prefer to retrieve and tie the sutures in the MLSP

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A

FIGURE 23-22. A, B: The anterior STIK stitches are passed using a curved Spectrum suture hook via the AMGP, and the Shuttle is retrieved via the MLSAP, always staying anterior to the previous sutures.

B

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Arthroscopic Technique for Reconstructing a Massive Nonrepairable Rotator Cuff Defect 351

A

FIGURE 23-23.  A, B: Pull the STIK suture tails to take

up the slack, roll the graft, and deliver it into the shoulder by pulling on the ends of the STIKs.

B

while viewing from the anterior or posterior portal (Fig. 23-24). 26. Continue tying the posterior edge STIKs working medially, and then tie the STIKs along the anterior edge from lateral to medial by first retrieving the free end and then the knotted end into the PMG cannula and tying them together.

Tying the Anchored Sutures 27. Retrieve both ends of the anterior anchored suture that passes through the anterior-lateral graft into the AMG or MLSA cannula. Cut off the knot and tie the sutures with a sliding-locking

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352 SCOI Shoulder Arthroscopy

A

FIGURE 23-24.  A, B: All the free ends of the STIK sutures are delivered from the posterior portal into the anterior portal, and then they are tied via the posterior portal, progressing from lateral to medial.

B

knot using the knotted end of the suture as the post. Repeat the process for the posterior anchor suture.

Suturing the Lateral Graft to Bone (The scope usually remains in MLSAP, but can be changed as needed for best visualization.) 28. Retrieve the medial end of the remaining suture from the posterior anchor into the AMG cannula. Pass a curved suture hook through the graft from top to bottom 5 mm anterior to the previous graft suture. ­Retrieve the Shuttle and carry it into the AMG cannula. Load the Shuttle, and carry the suture through

the graft and into the PMG  cannula. Retrieve the other end of the suture, and store them in colored plastic suture protectors (Suture Saver, ConMed/Linvatec, Largo, FL) outside the PMG cannula. Repeat the stitching for the anteriorly anchored suture and store it outside the AMG cannula in a ­Suture Saver (Fig. 23-25).

Inserting the Third and Fourth Anchors 29. Locate the centerline on the lateral edge of the graft that is marked with a 1-cm purple vertical line.

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Arthroscopic Technique for Reconstructing a Massive Nonrepairable Rotator Cuff Defect 353

A

FIGURE 23-25.  A, B: The anchored sutures are passed using a curved Spectrum hook from either the anterior or the posterior portal and shuttled through the graft.

B

Determine how wide a defect remains between the previously placed anterior and posterior anchors. If there is more than 1 cm on each side of the centerline, two double-loaded anchors are required. Most often, only one additional double-loaded anchor is required. If only one anchor is needed, insert it directly lateral to the resting position of the midlateral mark on the graft. Before inserting the anchor (or anchors), create additional bone marrow vents as needed. Pass the sutures through the graft from posterior to anterior,

and store each in a colored suture protector (Suture Saver) outside the PMG cannula (Fig. 23-26).

Tying the Anchored Sutures 30. Retrieve the sutures stored in the suture savers into the lateral cannula from an anterior-to-posterior direction using a crochet hook (Fig. 23-27). 31. Tie the sutures through the lateral portal so that the knots are on top of the graft (Fig. 23-28).

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FIGURE 23-26.  The third (and possibly fourth) anchor is inserted just lateral to the centerline on the graft, and the sutures are passed with the shuttle technique.

A

FIGURE 23-27.  A, B: The suture pairs are retrieved from the Suture Savers with a crochet hook into the lateral cannula.

B

354

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Arthroscopic Technique for Reconstructing a Massive Nonrepairable Rotator Cuff Defect 355

A

FIGURE 23-28.  A, B: The sutures are tied with slidinglocking knots via the lateral portal, ensuring that the knots are on the top of the graft.

B

Evaluating the Repair 32. Carefully evaluate and document the status of the entire repair. If there are any gaps along the edges, pass additional sutures. Turn off the fluid pump and observe as the bone marrow bubbles from the bone vents. This will form the Crimson Duvet, a red, velvety blanket of bone marrow clot extending from the tuberosity across

the suture line and covering the graft. The Crimson Duvet will bring a new blood supply that will form a rich matrix replete with platelets, their growth factors, and mesenchymal stem cells (Fig. 23-29).

Postoperative Treatment

Allograft ­recon for nonrepairable RCT

33. Support the arm in 15 degrees of abduction in a pillow immobilizer (UltraSling4, DJO Global, Carlsbad, CA). Begin elbow, wrist, and hand exercises and isometric

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356 SCOI Shoulder Arthroscopy

A

FIGURE 23-29.  A, B: With the scope in the lateral portal, turn off the fluid pump and observe the bone marrow ­“Crimson Duvet.”

B

scapula shrugs the evening of surgery, and add small pendulum circles at 1 week postoperatively. 34. Delay formal physical therapy for 8 weeks, and follow a slow, progressive program similar to that for a large and massive cuff tear. Pool therapy is very helpful at 6 to 8 weeks to allow passive motion without stress on the healing graft. Progress activities slowly with active assisted lifting allowed at 2 months. A gadolinium-­ contrast MRI scan at 3 months is suggested to document that the graft has healed. This information will help guide the progressive exercises and activities.

c SCOI EXPERIENCE USING GRAFTJACKET FOR RECONSTRUCTION OF MASSIVE NONREPAIRABLE ROTATOR CUFF TEARS Methods One hundred and six patients with 109 shoulders were treated with a GraftJacket allograft (GJA) reconstruction for a massive nonrepairable rotator cuff tear between March 4, 2003 and July 26, 2011. Many of these patients were evaluated at

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3-months and 1-year postoperatively with an intra-articular gadolinium-enhanced MRI. Two orthopedic surgeons and a musculoskeletal radiologist evaluated the MRI arthrograms to determine the status of the graft. These patients also completed a Visual Analog Pain Scale (VAS), simple shoulder test (SST), and Modified University of C ­ alifornia at Los Angeles (UCLA) Shoulder Scores preoperatively and  at multiple time points postoperatively. Data were collected at 3 months, 1 year, and 2 years after the procedure. Many of the patients had late follow-up between 2  and 7 years postoperatively.

Results The 3-month postoperative MRI evaluations demonstrated that 85% (90/106) of patients had an intact GJA, 15% (16/106) of patients had a GJA tear, and three patients did not undergo the MRI. At 1 year postoperatively, 74% (46/62) of the previously intact reconstruction patients had an intact GJA, while the other 26% (16/62) were found to have a new tear. Fortyseven did not undergo further advanced imaging. Preoperative outcome surveys were collected from 103 patients. Postoperative surveys were collected from 65, 53, 20, and 51 patients at the 3-month, 1-year, 2-year, and greater than 3-year follow-up, respectively. The SST significantly improved from a preoperative average of 6.2 to a postoperative score of 6.79, 9.37, 10.57, and 10.9, respectively, at 3-month, 1-year, 2-year, and greater than 3-year follow-up (all P < .001). UCLA scores significantly improved from 14.56 preoperatively to 23.34, 28.10, 30.4, and 28.78 at 3-month, 1-year, 2-year, and greater than 3-year follow-up, respectively (all P < .001). VAS scores improved from 3.3 preoperatively to 1.64, 1.01, 0.95, and 1.22 at 3-month, 1-year, 2-year, and greater than 3-year follow-up, respectively (P < .001 preoperatively compared with all postoperative time periods). Constant scores averaged 76 for patients at the final ­follow-up (>3 years) (20).

c CONCLUSION We believe that our experience and studies, as well as those of other researchers, have documented that certain types of acellular matrix allograft tissues are a viable solution for surgical salvage in selected cases of massive nonrepairable rotator cuff pathology. Of course, longer follow-up and more cases are mandatory to determine the longevity and viability of the graft as well as patient satisfaction. Arthroscopic techniques permit us to treat the entire joint, including biceps, subscapularis, labrum, synovium, etc., without damage to the deltoid or large skin incisions in an outpatient setting.

Frequently Asked Questions 1. How does a graft composed of dead skin become a tendon? The AHDA is a special kind of graft material. Because it is an allograft, much like a hamstring tendon graft used

for an anterior cruciate ligament (ACL) reconstruction, it has essentially all DNA and donor cells removed, and will not cause any antigenic response. The Crimson Duvet (bone marrow blanket) that issues from the tuberosity bone marrow vents provides a permanent source of new blood for the graft as well as a rich supply of mesenchymal stem cells that serve as the source of fibroblasts to regenerate the collagen and the cufflike tissue. The platelets from the bone marrow create a scaffold clot, and are a plentiful source of all of the growth factors needed to initiate, regulate, and modulate the healing and regeneration response. 2. Does a successful AHDA reconstruction allow atrophied muscles to regenerate? No. There is no way we know of getting fatty, scarred, retracted muscles to regenerate. A successful graft will often prevent further deterioration of muscles as seen on follow-up MRI scans. 3. What is the worst thing that can happen if the AHDA fails to heal? In our experience, when an allograft fails to heal, the patient still often achieves a good level of pain relief. This translates into better use of the shoulder, improved sleep, and a more satisfied patient. Of course, there is a price to pay for the cost and discomfort of surgery and physical therapy. If necessary, there is no reason that a reverse shoulder arthroplasty cannot be performed if and when the graft fails and significant pain is present. 4. What are the chances that the AHDA will heal? In our experience of nearly 180 cases to date, the chance that an individual graft will heal averages 70%. There are situations that improve the odds of healing, such as a smaller tear in a younger patient without arthritis, but there are no guarantees. 5. How can a surgeon learn and become proficient in performing this allograft surgery? The best way to learn the arthroscopic technique is to visit a center where the surgery is being routinely performed. Prior to visiting, it is advisable to review a comprehensive video of the surgery, memorize the steps, and practice them on an ALEX shoulder model (Sawbones, Inc., Vashon, WA). 6. Are there other graft materials that are as good as GraftJacket? There are numerous other graft materials available now. Each has its own characteristics. In our opinion, the best materials are from human dermis that is not cross-linked or irradiated, and is processed without freeze-drying. We have no doubt that there will be other good graft materials available soon, some of which will be man-made. At this time, we are not aware of any of them with the track record of laboratory, animal, and human study that are as encouraging as those of AHDA. 7. Why does this form of graft often improve the patient’s function? It is obvious that replacing or patching a nonrepairable rotator cuff defect with an allograft matrix will never

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358 SCOI Shoulder Arthroscopy

create a normal rotator cuff tendon. There will always be persistent weakness resulting from muscle atrophy, scarring, and capsular tightness. The most noticeable postoperative deficiency is weakness in external rotation, because there is no other muscle to compensate for the compromised infraspinatus. The healed rotator cuff allograft does, however, greatly improve shoulder pain, and it often helps with shoulder elevation strength. The theoretical basis for these improvements, though not proven, is illustrated by the following scenarios:

a. The viable graft may improve function by reattaching any remaining rotator cuff muscle fibers from the supraspinatus and infraspinatus tendon stump to the humeral tuberosity, allowing them once again to function in assisting with shoulder stabilization, elevation, and external rotation. In addition, if the fibers are viable, they may be able to be strengthened with postoperative exercise. b. The healed graft that acts as a bridge between the cuff remnant on three sides and the tuberosity may function

FIGURE 23-30.  A, B: This sequence of images documents a massive nonrepairable rotator cuff tear (orange arrows) that has been replaced by an allograft ECM. The gadolinium MRI scan at 1 year postoperatively reveals the healed graft (yellow arrows).

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as a stabilizing hood, serving to hold the humeral head in a more natural position within the glenoid socket by reducing proximal subluxation. This stabilizing function will assist the biomechanical force couple of the shoulder, improving the abduction power of the deltoid. This action is akin to closing the extensor hood in a boutonnière deformity of the finger. c. Having a smooth living soft tissue graft situated between the humeral head and acromion may reduce contact pressure and act as a cushion between the cartilage and the bone during elevation and rotation. d. Resealing the shoulder joint may improve the intraarticular milieu by reestablishing the capsule and joint fluid pressures and aiding in joint nutrition and physiologic balance. 8. Because use of AHDA is “off-label” for the FDA, what do we need to do if we want to use it in a patient? The “off-label” status of AHDA and all other extracellular grafts exists only when they are used for bridging a cuff defect greater than 1 cm. If a rotator cuff defect is so large that bridging or replacement is needed, the surgeon should inform the patient of the FDA “off-label” status and use the surgical technique that will best treat the patient’s pathology.

c CASE EXAMPLES: 1. The patient is a 56-year-old plastic surgeon. He tore his rotator cuff in a fall off his bike. His pain prevented him from comfortably operating as well as exercising, and interfered with his sleep. His young age, lack of arthritis, and high activity level made him a poor candidate for a reverse shoulder arthroplasty. His goal is to resume his work in surgery as soon as possible. 2. The patient is a 76-year-old retired engineer widower who enjoys playing golf. He had a fall on the golf course, and his subsequent MRI documented a massive likely nonrepairable rotator cuff tear. Although he is healthy, his age may make it less likely that his stem cells will be active enough to regenerate the graft. He lives alone and will have problems during the postoperative period caring for himself, especially the 6 to 8  weeks in the UltraSling (Fig. 23-30).

References 1. Cofield RH, Parvizi J, Hoffmeyer PJ, et al. Surgical repair of chronic rotator cuff tears: a prospective long-term study. J Bone Joint Surg Am 2001;83:71–77. 2. Galatz LM, Ball CM, Teefey SA, et al. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am 2004;86:219–224.

c SURGICAL PEARLS 1. The patient should have good passive and active assisted motion of the shoulder with minimal arthritis. 2. All graft materials are not alike. The rotator cuff graft must be chosen with care, avoiding materials that are weak or likely to incite inflammatory reaction, and those with cross-linked collagen, which are likely to retard cellular ingrowth. 3. The operation should be rehearsed in the ALEX model lab until the steps are second nature for the surgeon, the assistant surgeon, and the operating room staff. 4. The patient should understand that this operation, even when completely successful, will never result in a “normal” shoulder. There will always be weakness, especially with external rotation. 5. Never suture the graft with too much tension. The most important goal is to encourage the graft to heal. The natural elasticity of an AHDA will help protect it from suture cutout. As the graft is repopulated with host cells, it will attain a more tendon-like tone, and the elasticity will decrease. 6. Be very careful when positioning the patient for surgery. The prolonged surgical time will increase the risk of pressure points on the nerves and skin. 7. Develop arthroscopic skills to be comfortable using the scope in all three subacromial portals. 8. Never cross a suture over another, and keep each successive suture anterior and parallel to all others. 9. Do not allow slack in the sutures when pulling the STIKs into the shoulder by pulling the medial sutures first and taking up slack in all others. 10. Create numerous bone marrow vents in the tuberosity, allowing a rich Crimson Duvet to form over the graft and tuberosity.

3. Bigliani LU, Cordasco FA, McIlveen SJ, et al. Operative treatment of massive rotator cuff tears: long-term results. J Shoulder Elbow Surg 1992;1:120–130. doi:10.1016/​ 1058-2746(92)90089-L. 4. Harryman DT, Mack LA, Wang KY, et al. Repairs of the rotator cuff: correlation of functional results with integrity of the cuff. J Bone Joint Surg Am 1991;73:982–989. 5. Yamakado K, Katsuo S, Mizuno K, et al. Mekial-row failure after arthroscopic double-row rotator cuffrepair. Arthroscopy 2010;26:430–435. 6. Walch G, Madonia G, Pozzi I, et al. Arthroscopic tenotomy of the tendon of the long head of the biceps in rotator cuff ruptures. In: Gazielly D, Gleyze P, Thomas T, eds. The Cuff. ­Amsterdam, The Netherlands: Elsevier, 1997:350–355. 7. Rockwood CA, Williams GR, Burkhead WZ. Debridement of degenerative, irreparable lesions of the rotator cuff. J Bone Joint Surg Am 1995;77:857–866. 8. Frankle M, Siegal S, Pupello D, et al. The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: a minimum 2-year follow-up study of sixty patients. J Bone Joint Surg Am 2005;87:1697–1705. doi:10.2106/JBJS.D.02813. 9. Gerber C, Pennington SD, Lingenfelter EJ, et al. Reverse delta-III total shoulder replacement combined with latissimus dorsi transfer: a preliminary report. J Bone Joint Surg Am 2007;89:940–947. doi:10.2106/JBJS.F.00955. 10. Gerber C. Latissimus dorsi transfer for the treatment of irreparable tears of the rotator cuff. Clin Orthop Relat Res 1992;275:152–160. 11. Miniaci A, MacLeod M. Transfer of the latissimus dorsi muscle after failed repair of a massive tear of the rotator cuff: a two to five-year review. J Bone Joint Surg Am 1999;81:1120–1127.

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12. Aurora A, McCarron J, Iannotti JP, et al. Commercially available extracellular matrix materials for rotator cuff repairs: state of the art and future trends. J Shoulder Elbow Surg 2007;16(Suppl):S171–S178.

17. Bond JL, Dopirak RM, Higgins J, et al. Arthroscopic replacement of massive, irreparable rotator cuff tears using a GraftJacket allograft: technique and preliminary results. A ­ rthroscopy 2008;24:403–409.

13. Badylak SF, Freytes DO, Gilbert TW. Extracellular matrix as a biological scaffold material: structure and function. Acta Biomater 2009;5:1–13.

18. Burkhead WZ, Schiffern SC, Krishnan SG. Use of Graft Jacket as an augmentation for massive rotator cuff tears. Semin ­Arthroplasty 2007;18:11–18.

14. Derwin KA, Badylak AD, Steinmann SP, et al. Extracellular matrix scaffold devices for rotator cuff repair. J Shoulder ­Elbow Surg 2010;19:467–476.

19. Snyder SJ, Arnoczky SP, Bond JL, et al. Histologic evaluation of a biopsy specimen obtained 3 months after rotator cuff augmentation with GraftJacket Matrix. Arthroscopy 2009;25:329–333.

15. Derwin KA, Codsi MJ, Milks RA, et al. Rotator cuff repair augmentation in a canine model with use of a woven polyL-lactide device. J Bone Joint Surg Am 2009;91:1159–1171. 16. Adams JE, Zobitz ME, Reach JS Jr, et al. Rotator cuff repair ­using an acellular dermal matrix graft: an in vivo study in a canine model. Arthroscopy 2006;22:700–709.

20. Clark RR, Burns JP, Snyder SJ, et al. Human dermal allograft for reconstruction of massive rotator cuff tears: functional and MRI results of 109 patients. Presented at the Annual Meeting of the American Academy of Orthopaedic Surgeons, Chicago, IL, March 2013.

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24

Suprascapular Nerve Pathology c INTRODUCTION Suprascapular neuropathy is a relatively uncommon etiology for shoulder pain and impairment. However, it can be a significant source of morbidity and in the right patient can be easily corrected with great improvement. The etiology of the neuropathy will determine whether surgical intervention is indicated and dictate subsequent prognosis. Arthroscopic approaches to suprascapular decompression are ­reproducible and safe.

c ANATOMY

around the base of the scapular spine or the s­ pinoglenoid notch to supply the infraspinatus muscle. There are typically two or more motor branches (5,6). A safe zone has been ­determined where the nerve is typically 1.8 to 2.1 cm medial to the glenoid margin at the notch (2,5,7). ­Overlying the nerve at the spinoglenoid notch is the spinoglenoid ­ligament (4,8).

Transverse scapular ligament

The suprascapular nerve is primarily a motor nerve that innervates the supraspinatus and infraspinatus muscles (1,2). It predominantly arises from cervical roots five and six. From the cervical roots, it travels posteriorly to the suprascapular notch, which is medial to the coracoid process and glenoid (Fig. 24-1). The suprascapular notch is a bony space where the superior portion is covered with the transverse scapular ligament (TSL). Because of its rigid fibro-osseous anatomy, it can be a source of entrapment. The suprascapular artery and vein typically lie superior to the TSL, while the nerve passes inferiorly. The specific anatomy of the suprascapular notch can vary (3,4); the notch has been described as a mild depression to a fully enclosed bony tunnel with an ossified suprascapular ligament (3,4) (Fig. 24-2). After passing through the suprascapular notch, the nerve innervates the suprascapular muscle with multiple motor branches. It also receives some sensory branches from the glenohumeral and acromioclavicular joints (2,5). ­Subsequent to the supraspinatus fossa, the nerve passes

Supraspinatus muscle

Spinoglenoid notch Suprascapular nerve

Infraspinatus muscle

Suprascapular artery

FIGURE 24-1. The suprascapular nerve travels through the fibro-­ osseous tunnel of the suprascapular notch and suprascapular ligament to innervate the supraspinatus. It subsequently passes around the spinoglenoid notch to innervate the infraspinatus.

361

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Type I

Type II

Type III

Type IV

Type V

Type VI

FIGURE 24-2.  Six different suprascapular notch morphologies have been described, ranging from a Type I having a wide depression to a Type VI with a notch that is a fully ossified tunnel.

c PATHOLOGY Typical suprascapular pathology arises from the nerve’s unusual anatomical course. Because the nerve passes through a rigid fibro-osseous structure and then takes an acute turn around the base of the bony scapular spine, it has limited excursion and is at risk for injury (2,9). Suprascapular pathology can be roughly divided into two major etiologies: traction neuropathy and extrinsic compression. Extrinsic compression often arises from local masses such as paralabral cysts (10,11) that extend into the suprascapular notch (Fig. 24-3) or spinoglenoid notch and compress the nerve. Alternatively, fractures may change the shape and narrow either notch (12). Similarly, anatomical

variants can also cause abnormal fascial band compression. This has been reported in abnormal TSLs, subscapularis muscle fascial bands, and anterior coracoscapular ligaments (2,13,14). There have also been reports of enlarged veins and prominent hardware causing compression (15,16). Traction neuropathy is the other major source of suprascapular nerve injury. There is limited excursion of the nerve due to fibro-osseous restraints causing the nerve to be susceptible to injury from dynamic traction. This has been ­reported in volleyball players and pitchers (6,17–19). Similarly, ­ suprascapular nerve injuries have been reported in shoulder dislocations, proximal humerus fractures, and massive rotator cuff tears (9,20–23). With a large retracted tear, the ­supraspinatus motor branches may become compressed

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FIGURE 24-3.  A SLAP tear with resultant large paralabral cyst (arrow) that extends into the suprascapular notch.

at the notches. Cadaveric data suggest that 5 cm of retraction of the supraspinatus significantly changes the tension of the suprascapular nerve at the suprascapular notch (9).

c DIAGNOSIS History and Physical Examination Isolated suprascapular neuropathy presents as progressive, dull posterolateral shoulder pain, which results in isolated weakness with abduction and external rotation. However, it often presents with additional symptoms, depending on the etiology of the pathology. Trauma has been reported in 40% of patients, and it can radiate into the neck or arm (1,24). The pain may be worse with cross-body adduction and internal rotation as this position tensions the spinoglenoid ligament (6). Patients may also complain of weakness with abduction and external rotation if the supraspinatus and infraspinatus muscles are significantly affected. Suprascapular notch entrapment is more debilitating than spinoglenoid notch entrapment. S ­ uprascapular notch entrapment has been reported to result in up to 75% loss of abduction and external rotation, while the posterior deltoid and teres minor can compensate for isolated infraspinatus loss (18,25). With significant entrapment, supraspinatus and infraspinatus muscle atrophy is apparent on inspection. Identifying which fossa is atrophied helps localize the point of entrapment. Global strength testing and neurologic testing will help determine whether there is isolated entrapment or a more global plexus or radicular etiology.

Diagnostic Studies Proper radiographs will help evaluate the shoulder for osseous sources of entrapment. Signs of bony instability may point toward a traction etiology for the nerve injury. Scapular fractures with a malunion can be identified. A computed ­tomography (CT) scan may help visualize notch m ­ orphology if an osseous tunnel is suspected.

FIGURE 24-4.  A posterior labral tear with a paralabral cyst (arrow) that extends into the spinoglenoid notch. Magnetic resonance imaging (MRI) will help rule out soft tissue masses or cysts and associated labral pathology (Fig. ­24-4). It will also help quantify and localize the muscles affected as well as identify and quantify muscle atrophy if present. An electromyography–nerve conduction velocity (EMGNCV) study is routinely ordered to determine the preoperative degree of injury. Signs of nerve injury include fibrillation potentials, diminished amplitudes, and increased latencies. These tests are operator-sensitive, and should be performed by experienced and trusted diagnosticians. Even then, the tests may be falsely negative (17). If the diagnosis is suspected and the test is negative, it is reasonable to repeat the test in 4 to 6 weeks.

c TREATMENT The best treatment is determined by the cause of the entrapment. For overuse traction etiologies, nonsurgical management is typically recommended. Absence of any extrinsic source of compression, in milder cases, relieving the dynamic traction injury through rest will allow the nerve to recover. Activity modification, anti-inflammatory medications, and physical therapy for periscapular stretching and strengthening can be helpful (24). Chronic (>6 months) severe cases with significant atrophy will have limited recovery (1). ­ Serial EMG-NCVs will aid in the prognosis. Nonsurgical management in cases without an obvious mass lesion was reported to have an 80% good to excellent result after 6 months (24). However, persistent atrophy and mild weakness was common, and half of the patients ­possessed persistent EMG deficits.

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If a specific extrinsic source of compression is identified, surgical management consisting of correcting the extrinsic compression can be very effective. If a paralabral cyst is  compressing the nerve, correcting the labral pathology will correct the nerve entrapment. If the nerve needs to be decompressed at the notches, an open or arthroscopic approach should be performed. For the suprascapular notch, the traditional approach has been open with a trapezius split (26). The trapezius is split in line with its fibers, and the supraspinatus is retracted ­posteriorly to visualize the suprascapular notch and its contents. More recently, arthroscopic techniques have been advanced to reliably and safely visualize the notch and nerve (27,28). The benefit of the arthroscopic approach, which we prefer, is that additional glenohumeral or subacromial surgery can be performed at the same time. We prefer to perform our suprascapular notch decompression in the lateral decubitus position with subacromial arm suspension. Our surgical technique involves viewing through the standard lateral portal. An anterior portal is used as a working portal. A spinal needle confirms proper anterior portal placement by being able to follow the coracoacromial ligament to the coracoid tip and posterior to it. Once the proper working portal has been established, a subacromial bursectomy is performed to visualize the coracoacromial ligament. The coracoacromial ligament is then followed to the coracoid process (27). After the coracoid process has been identified, additional posteromedial dissection is carried out to identify the coracoclavicular ligaments (Fig.  24-5). Additional superior portals are created to help retract and dissect medially (27,28). A line bisecting the scapular spine and clavicle is created and two portals are made, an initial medial portal and a more lateral “suprascapular portal” (28) (Fig. 24-6). The initial medial portal is created 30 to 35 mm medial to the angle, and aids in initial dissection and retraction of the supraspinatus muscle.

FIGURE 24-5.  The coracoclavicular ligament is visualized posteromedially after identifying the coracoid process.

FIGURE 24-6.  Additional superior portals are created for supraspinatus

retraction, nerve dissection, and ligament release. The superomedial portal is created 30 to 35 mm medial to the angle of the acromion, while the superolateral portal or suprascapular portal is created 20 to 25 mm medial to the angle of the acromion.

FIGURE 24-7.  The suprascapular artery lies superior to the nerve.

FIGURE 24-8.  The TSL (single arrow) spans the superior aspect of the suprascapular notch. The suprascapular nerve (double arrows) lies inferior to the ligament.

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FIGURE 24-9.  Arthroscopic

scissors carefully divide the TSL while a switching stick retracts the nerve.

FIGURE 24-11.  The suprascapular artery lies superior to the nerve and

Careful dissection with a switching stick or probe will help identify the suprascapular artery above the nerve (Fig.  ­24-7). The suprascapular nerve lies inferior to the ligament (Fig. 24-8). The “suprascapular” portal is subsequently created 5 to 10 mm lateral to incise the ligament and decompress the nerve with arthroscopic scissors (Fig.  ­24-9). The nerve can be seen to be decompressed after the ligament is ­released (Fig. ­24-10). The suprascapular artery is easily visualized after the ligament is released superior to the nerve (Fig. 24-11). Decompression at the spinoglenoid notch can be performed in an open or arthroscopic fashion. For an open decompression, a posterior saber incision is created in line with the posterior joint line. The deltoid is split up to 5 cm from the acromion to avoid injury to the axillary nerve. The deltoid may be reflected

laterally for additional exposure if necessary. There is a distinct fascial layer overlying the infraspinatus. This is carefully incised, and a fat stripe heralds the central raphe of the infraspinatus. To access the spinoglenoid notch, the infraspinatus is gently retracted inferiorly. We have used this technique to remove errant SLAP repair suture anchors in the notch, which had injured the suprascapular nerve (Fig. 24-12). Arthroscopic spinoglenoid notch decompression can also be performed (6,8). Results of surgical decompression at e­ ither notch depend on the specific pathology. However, if a specific mass lesion is identified and removed, high rates of success have been reported Suprascapular (2,27,29,30). Nerve Release

FIGURE 24-10.  The suprascapular nerve (arrow) is decompressed with-

out the overlying suprascapular ligament.

transected TSL.

FIGURE 24-12.  A suture anchor is removed from the spinoglenoid notch from a previous SLAP repair at an outside institution. The freer points to the white suture anchor at the spinoglenoid notch.

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366 SCOI Shoulder Arthroscopy

References

c REHABILITATION After surgery, the rehabilitation will be guided by the concomitant pathology and surgery performed. If labral repair is performed, it will dictate the postoperative rehabilitation and need for an UltraSling. For example, after a SLAP repair, the patient would be in an UltraSling for 4 weeks, with gentle range-of-motion exercises and progressive formal physical therapy afterward. Similarly, if rotator cuff surgery is performed, this will be the primary rehabilitation variable. When isolated suprascapular ligament release is performed, the patient does not require protection and can begin immediate motion with activities as tolerated.

c CONCLUSION Suprascapular neuropathy is an uncommon source of shoulder pain and impairment. The etiology can be divided into either an overuse traction-type pathology or extrinsic compression. Patients with overuse pathology typically improve with activity modification and nonsurgical management. Those with a specific structural compressive etiology will benefit significantly from surgical intervention. Chronic ­injuries may not be reversible.

c PEARLS 1. Suprascapular nerve entrapment presents as dull posterolateral shoulder pain, and should be a differential diagnosis when considering sources of shoulder pain as an uncommon but important etiology. 2. Localizing the suprascapular nerve lesion is important, and can be performed with a combination of physical examination and diagnostic studies. 3. Suprascapular nerve entrapment is potentially an easily correctable source of pain. 4. Suprascapular nerve entrapment can be divided into two major etiologic sources: traction neuropathy and extrinsic compressive neuropathy. 5. Suprascapular traction neuropathy is a dynamic, excessive tensile stress on the nerve in repetitive overhead athletes, and is an overuse phenomenon. 6. Suprascapular traction neuropathy responds well to nonoperative management, but may have residual deficits depending on chronicity and degree of injury. 7. Diagnostic EMG-NCVs are very operator-dependent, and should be repeated if there is a high degree of suspicion with a negative test. 8. Suprascapular extrinsic compressive neuropathy can have an excellent outcome with surgical correction if the source of compression is identified and removed. 9. Suprascapular nerve entrapment, treated by release of the suprascapular ligament, can be safely performed arthroscopically with good results. 10. Massive rotator cuff tears may also place excessive tension on the suprascapular nerve complicating the prognosis.

1. Piasecki DP, Romeo AA, Bach BR Jr, et al. Suprascapular neuropathy. J Am Acad Orthop Surg 2009;17:665–676. 2. Warner JP, Krushell RJ, Masquelet A, et al. Anatomy and relationships of the suprascapular nerve: anatomical constraints to mobilization of the supraspinatus and infraspinatus muscles in the management of massive rotator-cuff tears. J Bone Joint Surg Am 1992;74:36–45. 3. Edelson JG. Bony bridges and other variations of the suprascapular notch. J Bone Joint Surg Br 1995;77:505–506. 4. Rengachary SS, Burr D, Lucas S, et al. Suprascapular entrapment neuropathy: a clinical, anatomical, and comparative study. Neurosurgery 1979;5:447–451. 5. Bigliani LU, Dalsey RM, McCann PD, et al. An anatomical study of the suprascapular nerve. Arthroscopy 1990;6:​ 301–305. 6. Planchar KD, Luke TA, Peterson RK, et al. Posterior shoulder pain: a dynamic study of the spinoglenoid ligament and treatment with arthroscopic release of the scapular tunnel. Arthroscopy 2007;23:991–998. 7. Shaffer BS, Conway J, Jobe FW, et al. Infraspinatus musclesplitting incision in posterior shoulder surgery: an anatomic and electromyographic study. Am J Sports Med 1994;22:​ 113–120. 8. Planchar KD, Peterson RK, Johnston JC, et al. The spinoglenoid ligament: anatomy, morphology and histological findings. J Bone Joint Surg Am 2005;87:361–365. 9. Albritton MJ, Graham RD, Richards RS II, et al. An anatomic study of the effects on the suprascapular nerve due to retraction of the supraspinatus muscle after a rotator cuff tear. J Shoulder Elbow Surg 2003;12:497–500. 10. Moore TP, Fritts HM, Quick DC, et al. Suprascapular nerve entrapment caused by supraglenoid cyst compression. J Shoulder Elbow Surg 1997;6:455–462. 11. Tirman PF, Feller JF, Janzen DL, et al. Association of glenoid labral cysts with labral tears and glenohumeral instability: radiologic findings and clinical significance. Radiology 1994;190:653–658. 12. Solheim LF, Roaas A. Compression of the suprascapular nerve after fracture of the scapular notch. Acta Orthop Scand 1978;49:338–340. 13. Avery BW, Pilon FM, Barclay JK. Anterior coracoscapu lar ligament and suprascapular nerve entrapment. Clin Anat 2002;15:383–386. 14. Bayramoglu A, Demiryurek D, Tuccar E, et al. Variations in anatomy at the suprascapular notch possibly causing suprascapular nerve entrapment: an anatomical study. Knee Surg Sports Traumatol Arthrosc 2003;11:393–398. 15. Maquierira GJ, Gerber C, Schneeberger AG. Suprascapular nerve palsy after the Latarjet procedure. J Shoulder Elbow Surg 2007;16:e13–e15. 16. Carroll KW, Helms CA, Otte MT, et al. Enlarged spinoglenoid notch veins causing suprascapular nerve compression. Skeletal Radiol 2003;32:72–77.

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Chapter 24

17. Ringel SP, Treihaft M, Carry M, et al. Suprascapular neuropathy in pitches. Am J Sports Med 1990;18:80–86. 18. Ferretti A, Cerullo G, Russo G. Suprascapular neuropathy in volleyball players. J Bone Joint Surg Am 1987;69:260–263. 19. Sandow MJ, Ilic J. Suprascapular nerve rotator cuff compression syndrome in volleyball players. J Shoulder Elbow Surg 1998;7:516–521. 20. de Laat EZ, Visser CP, Coene LN, et al. Nerve lesions in primary shoulder dislocations and humeral neck fractures: a prospective clinical and EMG study. J Bone Joint Surg Br 1994;76:381–383. 21. Costouros JG, Porramatikul M, Lie DT, et al. Reversal of suprascapular neuropathy following arthroscopic repair of massive supraspinatus and infraspinatus rotator cuff tears. Arthroscopy 2007;23:1152–1161.

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24. Martin SD, Warren RF, Martin TL, et al. Suprascapular neuropathy: results of non-operative treatment. J Bone Joint Surg Am 1997;79:1159–1165. 25. Gerber C, Blumenthal S, Curt A, et al. Effect of selective experimental suprascapular nerve block on abduction and external rotation strength of the shoulder. J Shoulder Elbow Surg 2007;16:815–820. 26. Post M. Diagnosis and treatment of suprascapular nerve entrapment. Clin Orthop Relat Res 1999;368:92–100. 27. Lafosse L, Tomasi A, Corbett S, et al. Arthroscopic release of the suprascapular nerve entrapment at the suprascapular notch: technique and preliminary results. Arthroscopy 2007;23:34–42. 28. Bhatia DN, de Beer JF, van Rooyen KS, et al. Arthroscopic suprascapular nerve decompression at the suprascapular notch. Arthroscopy 2006;22:1009–1013.

22. Mallow WJ, Bronee PR, Spinner RJ, et al. Suprascapular neuropathy after distal clavicle excision. Clin Orthop Relat Res 1996;329:207–211.

29. Kim DH, Murovic JA, Tiel RL, et al. Management and outcomes of 42 surgical suprascapular nerve injuries and entrapments. Neurosurgery 2005;57:120–127.

23. Mallon WJ, Wilson RJ, Basamania CJ. The association of suprascapular neuropathy with massive rotator cuff tears: a preliminary report. J Shoulder Elbow Surg 2006;15: 395–398.

30. Fehrman DA, Orwin JF, Jennings RM. Suprascapular nerve entrapment by ganglion cysts: a report of six cases with arthroscopic findings and review of the literature. Arthroscopy 1995;11:727–734.

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25

The Shoulder Patient’s ­Perspective: Through the Eyes of a Shoulder Surgeon You cannot appreciate what it’s like to be a patient until you’re on the other end of the knife. Yes, as an orthopedic patient, I’ve had both of my knees “scoped” and a cyst removed from my back. I’ve been on the other end of the knife. But after those surgeries, I enjoyed a quick uneventful recovery. I went out for dinner the same night and was back in the office, resuming my surgical practice after the weekend. My shoulder surgery, however, was quite another story! After too many years playing in an adult baseball league, I finally tore my rotator cuff. Not throwing out a runner at home plate but, rather, throwing a bag into the trunk of my car. Although this injury was not quite as glorious as many of the sports injuries we see, this simple event was the last straw (or last few fibers) of a compromised rotator cuff suffering from many years of sports trauma. I heard and felt the tear, and sensed a sharp pain at the supraspinatus area. Before long it was time for my repair, and I would soon find out what it was really like to be a shoulder surgery patient. I’ve drawn on this experience as well as those of others to present my personal experience as a shoulder surgery ­patient, beginning with the initial consultation, through treatment, to the end result.

before that office visit. The patient somehow must find your name and contact information from someone else: a friend, a family member, the insurance book, the Internet, etc. But how patients find you (marketing) is beyond the scope of this section, so we’ll start with making an appointment. What is it like for the prospective patient to get an appointment with you? Are you a busy surgeon whose patients must wait to get an appointment for weeks? Do you care if the ­patient will opt to go somewhere else rather than wait to see you? How easy is it for the patient to speak to someone when they call? Do they wait on hold for 15 minutes listening to a recording about the services your group provides? Does the prospective patient get to speak to an appointment agent right away, and is this person friendly or rude? Is there a long list of questions your agent must ask before making the appointment? Ask yourself whether any of this is important to you. These are some of the hurdles that your soon-to-be patient must navigate before they ever meet you. It may be something to think about.

c THE CLINIC EVALUATION

c GETTING AN APPOINTMENT

The Waiting Room: How Long Should I Have to Wait?

Because my choice for medical care was in the Southern California Orthopedic Institute (SCOI) group, I didn’t have to deal with this aspect as most patients do. The first encounter for your patient starts with making the initial appointment. But the actual interaction begins well

So the patient schedules an acceptable appointment for the first visit, and the day is here. Unfortunately, they are not able to see you right away. There is a long list of preliminary steps before that will happen. Often, they might have had difficulty getting time off from work, finding a baby sitter, 369

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370 SCOI Shoulder Arthroscopy

locating the office, finding a parking spot, but finally they are here. They find their way to your clinic where they’re greeted by the receptionist (hopefully warmly) and given a packet of preliminary paperwork to complete (much of it ­often redundant) while their insurance status is verified. After the paperwork is completed, they may be taken to the exam room or maybe they’re not. Maybe they wait. And wait. And wait. I regret to admit, occasionally I have personally had patients wait to see me for over 2 hours. This is a terrible beginning of a relationship for everyone involved. If that happens in your clinic, you are probably already having a tough day. Often then, the first thing the patient does (if they didn’t ­already walk out) is complain about the frustrating wait, which causes even further delay and definitely starts your new doctor–patient relationship off on the wrong foot. The best way to minimize a confrontation between the patient and either your staff or yourself is to anticipate and communicate. If the clinic is running behind, try to text or call the patient’s mobile phone with the expected wait time before they arrive. Routinely update those already in the waiting room. And, of course, always be sincerely apologetic when you first greet the patient. Start off with the apology before the explanation. Ultimately, I will remind the patient that in the office of a surgical practice unexpected situations often occur, which can lead to delays. I also explain that it is my custom to always answer all questions and never cut a patient off. Some conditions and/or treatments are extremely complex, requiring unusually lengthy discussions and prolonging the duration of a previous appointment. Finally, we can move on to the reason they’re here.

The History: Trying to Explain My Pain We are taught in medical school how to elicit a complete history, asking all the important questions: what, where, when; injury or not; severity, provoking activities, radiation; dull, throbbing, or sharp; do you have neck pain, other arm pain, or tingling; old injuries, previous surgeries, contralateral pain. We all know the questions to ask. But have you ever tried to describe your own pain to someone else? It’s not easy. Because the shoulder is a big joint and the pain is ­often referred, communicating the pain to the physician can be extremely challenging. The patient’s shoulder pain may ­ originate from the neck and manifest in the trapezius or ­humerus. Many patients with a shoulder condition (even a cuff tear) may have no shoulder pain at all but instead symptoms located at the mid-humerus. Even the best diagnosticians have been fooled, and that makes the physical exam all the more important.

The Physical Exam: What’s It Like to Have Your Shoulder Examined? Have you ever personally experienced a shoulder examination? Have you tried to relax it when someone else is twisting and pulling on it while asking you to relax? This is

something you do many times a day, but for your patient, it may be the first time a stranger has touched them like that. Many patients are not comfortable having their shoulder exposed. If it’s a male, do you ask him to take his shirt off? As doctors we take it for granted, but a man may be selfconscious about the way he looks without a shirt. This alone may make it difficult for him to relax. And some men may not like being touched by other men, or may feel awkward being touched by a female surgeon. What about the female patient? Do the gowns in your office have sleeves or do they have an elastic band that goes over the chest and under the axilla? Do you have the female patients take their bras off before putting on their gowns? What do you do with the bra strap overlying the AC joint? How do you deal with the self-conscious female patient when you’re a male doctor? Or perhaps, even more difficult, how do you deal with the female patient who has no qualms about showing you much more than is necessary? For the two scenarios mentioned above, it’s best to have a female assistant in the room with you. This might be the best practice when examining the shoulder of any female patient if you have the luxury of enough staff in your office. But even if you don’t have that luxury, it is a good practice to do it anyway when either you or the patient is uncomfortable. For all situations and all gender patient–doctor combinations, it’s best to remember that, even though you do this all the time, it’s likely the first time for the patient. Communication is the key. Tell the patient what you are going to do before you do it. Warn them if your hands are cold. Ask them whether they can move their bra strap over, or tell them you’re going to move it before you do it. If you want the p­ atient to relax, you have to put at ease any apprehensions they may have. A more common reason for the patient’s apprehension is that they think you’re going to cause them pain. And they are often correct. When you examine your patient, you are trying to reproduce their pain by either palpating or provoking the symptoms. This may lead to guarding, which further stresses the patient. There is really nothing you can do about this except to try to allay their fears while explaining that you need to perform certain tests to diagnose their condition. You will often need to adjust your exam on the basis of the patient’s sensitivity and pain tolerance, working together in essence to glean diagnostic clues. Additional clues will be derived from imaging tests.

X-rays and MRIs: Why Do I Need Them? It is probably common practice these days to obtain radiographs at the patient’s initial visit. Some shoulder surgeons won’t perform an initial consultation without an MRI. ­Regardless, what does the patient think of all of this? Some patients don’t care. Some refuse because they “know” they don’t have a bone problem, while others are concerned about the effects of radiation. Surgeons have their own opinions about these issues as well. I explain to patients that x-rays have minimal radiation, and that understanding the shapes and relationships of the bones as well as the condition of the joints is an important aspect of the evaluation. “As a bone doctor I need to know what the bones

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The Shoulder Patient’s ­Perspective: Through the Eyes of a Shoulder Surgeon 371

Understanding the Condition: What Do I Have and What Does It Mean?

FIGURE 25-1.  My preoperative MRI: a musculotendinous bursal-sided tear of the supraspinatus. look like.” And when the cartilage, tendons, muscles, and ligaments need to be evaluated, MRI is an excellent tool (Fig. 25-1). That is what I explain to the patient—but what if I’m not there?

Why Am I Being Seen by a Resident, a Fellow, or a Physician Assistant? Well, actually, that’s an excellent question. Many surgeons work in teaching institutions where residents and fellows are being trained. While this concept seems simple to us as surgeons, it may not be as clear to the patient. Some surgeons will just have the trainee shadow them in the clinic. Many will have the resident or fellow go into the exam room first to take a history, examine the patient, and make sure the proper studies are available before the attending physician visits the patient. Other medical practices utilize Physician Assistants (PAs) and have those PAs see patients for initial consultations. They will take the history, perform an exam, and make sure all proper diagnostic studies are ordered and done before the patient returns another day to see the surgeon. Regardless of the surgeon’s protocol, the patient needs to be in the loop ahead of time. You don’t want a patient that took a day off from work, got lost on the way to your office, spent half an hour trying to find a parking space, filled out forms in the waiting room, and then waited a­ nother 45  ­minutes in the exam room, only to find out when the door finally opens that they’re being seen by someone else ­besides the surgeon they chose. If your practice uses alternate practitioners besides you, the patient should understand who will be seeing them, what that person’s credentials are, and why they are not seeing the surgeon they thought they were making the appointment with.

Perhaps you have figured out what the patient has, or maybe you haven’t. Regardless, once you’ve done your history and physical exam and reviewed the imaging tests, it’s time to give the patient a diagnosis, telling him or her what you think is causing the shoulder problem. And then explain it. For most patients, you can spend a lot of time with a verbal explanation of their condition and all of the treatment options. Then by the time they get home, they’re either confused or forgot most of what you told them. Short of giving the patient a videotape recording of your explanation, there is no easy solution, but visual aids can help. Using the ­patient’s films, diagrams, and models will go a long way in assisting their understanding of their condition. What does the patient understand looking at those blackand-white radiographic images? Explain them. Show them the structures on the 3D model, then the 2D diagrams, and then point to the structure on their x-ray or MRI. Show them what normal looks like so that they can see the difference for themselves. They will not only understand their condition better, but they’ll appreciate the time and diligence you take to explain it to them. There are beautiful brochures and Internet web sites that are excellent tools for the patient to not only understand their diagnosis and treatment, but also to remember it and explore more about it when they are home. Keep in mind, though, that on the Internet they might also find contradicting information, which may cause them to become more confused. Having a sophisticated up-to-date web site for your own office that contains the information that you wish to share with the patient is an invaluable educational tool. What if you’re not sure of the diagnosis, even after all the appropriate testing is done and all the conservative treatment has failed? Some doctors are reluctant to tell the ­patient, “I don’t know.” Sometimes after all your testing (neck and shoulder MRI, EMG, etc.), you’re confident that there’s nothing serious going on, but you can’t explain the cause of their symptoms. Ultimately, it’s better to be honest and tell them so. It might be wise to consider seeking consultations with a neurologist, rheumatologist, or pain care specialist.

Understanding the Treatment Options: How Will You Make Me Better? No doubt, when the time comes to explain to your patient the treatment you suggest to make them better, there are numerous approaches to handling this discussion. I like to divide treatment options into three categories: no treatment, nonoperative treatment, and surgery. Some conditions clearly need surgery; others clearly do not. Sometimes, it is perfectly fine to do nothing and give it time. My approach, after making sure the patient clearly understands their condition, is to present the treatment options with the likelihood of success of each one. Surgeons, of course, have different opinions on the success of treatment options as well. For i­nstance, I’m not a big fan of nonsteroidal anti-­inflammatory medicines. I believe the significant complications that can occur from

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372 SCOI Shoulder Arthroscopy

them outweigh their occasional efficacy. Other surgeons may write prescriptions for everyone. Some ­patients may choose a steroid injection over physical therapy, others may choose the opposite, while many may want both. But the key is to list the options that exist, to present the expectations of each option, and to have the patient participate in the decision-making process. Your expertise will guide them while they’ll be happy to know that you care what they think. When evaluating and treating young children, a parent or legal guardian should be present. I always try to engage both the patient as well as the parent in the discussion of the condition and treatment. Sometimes, the interaction between difficult teenagers and their parents can become uncomfortably heated. I try not to take sides, but I attempt to guide both of them with my recommendations. How should you deal with the patient who comes to see you for a second opinion? My approach is for the most part the same except for one detail. I tell the patient from the start not to tell me what the first doctor said. This way the patient knows they are getting a true, independent, second opinion without worrying that I just copied the initial doctor’s impression and plan. Typically, once they see the time I take to explain their condition (especially if it is a significantly better job than their initial doctor), they feel more comfortable having me as their treating physician. So how do you react when a patient, after seeing you for their initial consultation, tells you they want a second opinion? Do you get insulted? Do you try to dissuade them? I ­encourage them. If I were making a decision on whether or not to have a major surgery, I would likely get two or three opinions. I often tell my patients that if they are even considering getting a second opinion, it’s better to do that before surgery than after. When planning for my own shoulder surgery, I e-mailed my MRI to all of the shoulder specialists in our group before making a decision. That gave me 10 ­opinions. And not everyone agreed! Patients should feel comfortable about their treatment decision, and if that means more opinions, so be it. I try to facilitate it by making shoulder-specialist recommendations, first asking the patient whether they prefer to stay in the group or go out of the group for their second opinion. The nature of the discussion between the surgeon and their patient, as is true of any discussion between two people who have just met, is guided by the personalities of those having the discussion. You know your personality. As the initial consultation proceeds through the history, exam, and discussion, you begin to appreciate the personality of the patient and adjust the way you interact with them as you proceed. At the same time, the patient is doing exactly the same thing—they are judging you as well. They’re trying to decide whether you’re knowledgeable, smart, skillful, confident, and compassionate. Do you rush in and out of rooms without explaining much to the patient? They may think you’re a great doctor, but get the impression that all you want to do is operate on every patient that walks in the door. And as the saying goes: “you don’t get a second chance to make a first impression.” So you’ve explained the condition and reviewed the treatment options. What if the patient wants an injection?

Steroid Injections: Is That Needle Going to Hurt Me? So the patient decides on a steroid injection. How do you walk the patient through a shot? Many patients, especially those being seen for their first orthopedic condition, have never had a steroid injection before. Most patients are fine, but others may be apprehensive or truly frightened. How do you allay their fears? Some of them may want to close their eyes, but I still tell them every step just before I do it. It’s best not to surprise them. Ethyl chloride skin spray is very helpful because it briefly numbs the injection site, decreasing the pain from the needle. Having bicarbonate mixed in the lidocaine can lessen the sting, but I still tell the ­patient they will feel a burning sensation and pressure for 5 to 10 seconds as the fluid is injected. Do you explain what the steroid does and what the expected outcome is from a shot? Do you tell the patient that once the numbing medicine wears off, the pain may be worse for up to 24 hours? Do you remember to tell them that if they are a type I diabetic to check their glucose more closely for the first 48 hours as their sugar will likely shoot up, requiring more insulin? When do you tell them the benefit of the steroid will begin, how long it should last, and what the success rate is? I believe that the key is to give the patient a range of expectations. I tell them that, typically, they should be improved for the first couple of hours (depending on which anesthetic you mixed your steroid with). But when that wears off, for the first 24 hours, the shoulder may be more painful than before the injection. As the cortisone begins to take effect, the shoulder will begin to feel better, but it may be anywhere from 2 to 7 days. I also explain to those who have had a successful shot before that even with the same patient, the same doctor, and the same body part, no two injections are exactly alike. Some may work for months or years, while others last for weeks or not at all. If the shot lasted a year, it’s not that the steroid is still working, but rather that the inflammation didn’t return after the steroid had worn off. The way you give the shot will tell the patient a lot about what kind of doctor you are and will give them the confidence in you they will need, if and when they need to proceed with surgery. Most initial consultations go smoothly without a second thought. But then there are those patients who are difficult to deal with.

Difficult Patients: Me? Am I Being Difficult? Here’s a short list of some of the more common categories: The know-it-all patient: This patient went to the Internet and already has their diagnosis before stepping in the office. They know what they have, what treatment they need, and if you disagree with them, you obviously don’t know what you’re talking about. Solution: If you can’t convince them they’re wrong, tell them to find a doctor who does agree with them. The indecisive patient: This patient can’t make any ­decisions about how they want to proceed with their care. Solution: Tell them to go home to think about it and come back or call when they’ve decided.

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The Shoulder Patient’s ­Perspective: Through the Eyes of a Shoulder Surgeon 373

The frugal patient: This patient doesn’t want to pay their deductible or co-pays, and they want a professional courtesy because a friend or relative is related to someone you know. Solution: Tell them your staff, not you, deals with the financial issues. Tell your staff to tell them they have to pay. The demanding patient: This patient wants immediate ­attention and immediate results, not only from you but from your entire office staff as well. They want direct contact numbers and e-mail addresses, and they don’t want to wait long to be seen. Solution: The results you can’t predict, but I’ve found that if you and your staff do your best to give these patients a little extra attention, not only do they ­appreciate it but they become loyal patients and a great ­referral source. The worker’s compensation patient: This patient, notoriously often, would rather collect benefits sitting at home than get better and return to work. I have found, however, that there are a significant number who truly do want to get better. Solution: Try to treat only objective pathology and figure out who really wants to get better. Parents of athletes: Of course, there are two types: the reasonable parent with perspective, and the parent whose child will, without a doubt, be a professional athlete. If their child misses any games or practices, they will jeopardize their chance of getting a scholarship or making an all-star team. Solution: In my experience, the best way to deal with these unrealistic parents is not to try to give them a dose of reality. That will never work. An uninformed doctor does not know about the athletic potential of their child. I have found that it’s better to go along with it. Remind the parent that in order for their child to be that superstar, their bodies need to be treated properly, especially when injured. Sometimes despite all efforts, personalities clash and you can’t get along with a patient. You may figure it out at the initial visit, or it may take a few interactions. Regardless, if and when it happens, it may be best to just recognize it and transfer the patient’s care to a colleague, or better yet, out of the group!

c COMMUNICATING WITH THE OFFICE: WHY CAN’T I GET THROUGH? After the initial consultation, the patient usually leaves with a treatment plan. That plan will often require some communication with your office. How easy is it for the patient to speak to someone who understands patient care? Can they reach a member of your staff directly, or do they need to leave a message? How long does it take for your staff to return calls? Is your assistant a good people’s person? Can the patient communicate by e-mail? How does the patient get test results? Do you discuss them over the phone with the patient, have an automated recording with their results, or have them return for another visit? Is the return visit with you or your PA? Is it okay with your patient to see someone besides you? Is it difficult getting a return appointment? Is their appointment constantly being changed because you’re often rearranging your schedule? Do you ever think about these things? Or do you only worry about your patients if they’re going to have surgery?

c THE SURGICAL DECISION: SHOULD I PROCEED WITH IT? If surgery is recommended for a curable cancer or a failing heart valve, the need for surgery is likely clear and the decision is an easy one. The “need” for shoulder surgery is on a different level. The surgeon considers the pathology: fullthickness rotator cuff tears, recurrent instability, or a painful condition that has failed conservative treatment. But there are other nonmedical factors that are important to the patient that are a part of the decision process. Lifestyle, family, employment, and insurance issues play a significant role in the timing of a surgery, as well as whether or not to have it at all despite the surgical indications. Once the patient decides to proceed, there are many things that need to take place, usually all coordinated by your surgery scheduler. Your staff will need to interact closely with the patient to work out the financial/insurance issues, which are often complicated for everyone. Sometimes, this can be more stressful than the decision to proceed with the surgery itself. It is another reason why your scheduler needs to be a “people” person. They need to be able to explain the complex insurance details with your patient and be understanding if the patient gets frustrated. Once the surgery is approved, deductibles and co-pays are worked out, deposits are made, and a date is set. Medical clearances, blood work, chest x-rays, and EKGs are all scheduled. Additional frustrations can arise for the patient if there’s an abnormality precluding medical clearance. Many surgeons schedule the patient for a preoperative visit to review the medical clearance and preoperative testing. The preoperative instructions are reviewed, including the cessation of certain medications, NPO instructions, and a reminder that the patient needs a ride home if the surgery is in the outpatient surgery center. They can have their postoperative sling fitted to them at this visit. The option of postoperative cold therapy can be explained and ordered. This is also a good time to go over the sequence of events that will take place on the day of surgery, including changing into a gown, receiving an IV, and any regional blocks that will be performed. You can explain to them what their bandage will look like when they wake up and what the recovery room will be like. Tell them what clothes they should wear home and what their early postoperative instructions will be, including any early range-of-motion exercises you may want them to start before their first postoperative visit. Warn them what it will be like to function with one arm. Brushing their teeth and toileting may need to be done with the opposite hand. In the shower, washing their hair and toweling off with one hand will be cumbersome. Simple things that we take for granted every day will be a challenge. Remember, you do shoulder surgery all the time, but it might be the patient’s first operation, first outpatient surgery, first regional block, etc. The more that’s explained to the patient ahead of time, the less apprehensive they’ll be on the day of the procedure. Everything that’s discussed can be written down in a handout for the patient to review when they get home. Some surgeons have a premade video explaining all of the above that the patient watches at this visit, and then they take a copy home with them.

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Surgical paperwork is filled out and the surgical consent is signed. This is the best time, if you haven’t done so already, to review the possible risks and complications with the patient. This discussion might add to the patient’s apprehension, but it can’t be avoided. In addition to the consent, it’s a good idea to document the details of this conversation in the patient’s medical record. Make sure all their questions are answered so they’ll be as prepared as possible for their surgery.

c DAY OF SURGERY: AM I REALLY GOING THROUGH WITH IT? As most shoulder arthroscopy these days is performed in outpatient centers, the patient will typically arrive 1 hour early. They are immediately handed more paperwork, more forms to fill out, and another surgical consent with more alarming small-print warnings. They change into an immodest gown, meet the admitting nurse, and at some point see their surgeon, who will mark the surgical site. “Why does he have to do that? You mean it’s possible he could operate on the wrong side?” More apprehension. The patient next meets the anesthesiologist who does his or her best to explain how a shot in the neck or above the clavicle will make the ­shoulder less painful after surgery. Finally the patient goes off to sleep. This is the only time you don’t have to worry about what the patient is thinking (Fig. 25-2). During the surgery, however, there is another opportunity for patient education that you can consider. You can take intraoperative photos and make copies for the patient and/or give the patient a copy of the DVD video. The video can be captured with or without audio. You can record just highlights of the procedure or a more extended presentation of

the important steps of the arthroscopy as it is performed. I’ve heard many arguments for and against taking photos, and for and against giving the patient a DVD video. Obviously, the surgeon should choose the routine he or she feels comfortable with. It’s been my experience both as a shoulder surgeon and as a shoulder patient that, with few exceptions, it is very difficult to understand orientation and anatomy from intraoperative photos. I typically give the patients an extended version of the DVD, with an audio track that demonstrates both the original pathology and important steps of the repair. After viewing it, patients have a better understanding of their problem and are invariably impressed with the surgical technique. It also confirms and documents for them that their problem is fixed. In addition, if there is pathology that cannot be repaired such as arthritis or an o­ steochondral defect, it can be documented for the record. Do you speak to the patient’s family or friends after surgery? Not all doctors do, but I believe it’s a common courtesy, not to mention another opportunity to reinforce your relationship and concern for them. The family has been sitting in the waiting room, nervous, not just about the surgery you did, but often about the anesthesia too. My first words to the family are always “he (or she) did great.” Right away their worst fear (an anesthetic complication) is allayed. Then I proceed to tell them what I found, what I did, and the prognosis. Next I go over the discharge instructions (reminding them that everything is written down), and finally, I tell them how long till the patient can go home. After surgery, the patient wakes up, and most often their regional block was successful, but if it wasn’t, they may have shoulder pain. Sometimes they wake up nauseated. They should have been warned about this ahead of time. Eventually, although they may still be groggy, with a bulky bandage and cumbersome brace on their shoulder, they go Explicit discharge instructions should be written home. ­ down regarding the bandage, cold therapy, and nerve block, as well as a 24-hour contact phone number in case they have questions. This information should all be reviewed by the discharge nurse with the person responsible for taking them home. In the next few days, they can start the exercises you gave them before their first postoperative appointment. It’s a very prudent practice to call the patient or family the evening of surgery or the next morning to answer any questions and check on the status of the nerve block and pain level.

c AFTER SURGERY: THE HARD PART IS DONE—OR IS IT? Early Postoperative Period (the First Week)

FIGURE 25-2.  In good hands on the operating table.

Having personally experienced shoulder surgery, there is no doubt that this is a very difficult time for the patient on many levels. Without a doubt, it’s much better to be recuperating at home than to stay overnight in a hospital, but at home there can be a feeling of insecurity. Your patient is still groggy, possibly nauseous, likely in pain, tied up in a cumbersome bandage, and attended to by eager but inexperienced family members trying to help them. They may wish that recovery room nurse were still with them.

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Again, this early postoperative period is when that preoperative discussion would prove invaluable. If you or your staff did a good job, your patient is prepared for this difficult time. They know what to do when the block starts wearing off, which medications to take, how much and when, as well as what to do with the bandage and cold therapy or ice. They know whether, when, and how to wear their sling. They were instructed on how to do ADLs, including bathing, eating, and using the toilet. They were told that sleeping would be difficult, and they will either need to prop up the back of the bed with pillows or sleep in a recliner. They were warned that the effects of the general anesthesia could linger for a few days, and they were given instructions on whether or not they could drive. You may have started them on early exercises. Of course, they were given a postoperative appointment and a 24-hour contact number in case of questions or an emergency. My biggest problem that first week was some mild lingering effects from the anesthesia, which I didn’t anticipate. Although I was back in the office in 3 days, taking a week off might have been more prudent. It was a good thing I didn’t schedule any surgery right away. It’s best when all of these instructions are written down or, better yet, documented on a preoperative video. A handout should be in as much detail as possible. Don’t forget, it’s usually the patient’s first time going through this. It makes it harder to follow instructions when you’re groggy, nauseous, and in pain. The clearer it is for the patient, the happier they’ll be and the less you will be called. I give the patient separate instruction sheets for the bandage, nerve block, and cold therapy and exercises. This will get them through this difficult time until they get to see you again.

First Postoperative Appointment By now most of the patient’s worst pain is gone. I like to check the wounds, and if any bone work was done or metal anchors were placed, I get postoperative x-rays. By comparing these x-rays with those taken preoperatively with the aid of diagrams and/or models, you can explain to the patient what was done. Other instructions are given at this time regarding sling or brace use, exercises, PT, and ADLs. Additionally, you can outline for the patient what the remainder of their postoperative course will be like—when they can expect pain relief, full motion, strength, and return to their usual activities, including sports.

Mid-Postoperative Period (2 to 8 Weeks) This period of time is similar for most patients, regardless of the surgery performed and regardless of their own personal progress. Subject to the procedure and your particular protocol, patients will be starting their PT and discontinuing their sling. Depending on their profession, they may be returning to work. The disparity between patients starts after this point.

Later-Postoperative Period (2 to 6 Months) Most patients are now out of their sling and are progressing with physical therapy and home exercises. But there are ­numerous factors that lead to their difference in progression.

These include but are not limited to the type of procedure performed, length of time of immobilization (compliance with immobilization), compliance with PT and home exercises, age, general health, pain tolerance, incentive to ­improve (e.g., worker’s compensation), and those factors we don’t understand, such as patient physiology and the variability of the human body’s innate ability to recover from injury—whether or not they’re a “good healer.” How often do you or your staff see the patient back? It depends of course on the operation performed and the patient’s personal situation. Some patients progress slower and need more feedback, encouragement, or direction, while others are more independent. During this time, if the patient needs a lot of feedback, it may come from too many different places and can occasionally be contradictory. You tell the patient one thing, the physical therapist tells them something else, but their neighbor has another opinion. You can’t control what the neighbor tells them, but you can do a lot of damage control by working with therapists familiar to you, who know your protocols and who know not to contradict the surgeon. During this period, patients are getting their functional mobility back, they’re regaining their strength, their pain is lessening, and they’re finally able to sleep flat in their bed. Patients like to know when they’re healed. I have to explain to them that healing doesn’t occur on a specific day. It’s a gradual process. I noticed improvement after my surgery for over 2 years. I tell them that generally it takes 8 to 12 weeks for soft tissue (rotator cuff, labrum, etc.) to heal to bone, but there is still a lot of scar tissue that is firm and gradually softens over 4 to 6 months. A good rule of thumb is that a medium rotator cuff tear heals at a rate of 20% a month; more complicated, degenerative, and chronic tears heal slower. Isometric scapular strengthening is good to start early, and can be done without damage to the reconstruction. I emphasize that the most urgent goal is restoration of their shoulder mobility. They can always strengthen later, but if they don’t get their motion back in the first few months, they will be stiff for a prolonged period. Patients will often feel catching or popping in their shoulder as they are progressing with their motion. I tell them it could be scar tissue or fluid in the bursa and it’s a common feeling after surgery, which will go away. When can the patient be discharged from PT (Physical Therapy)? I personally rely on the therapist and the patient to decide this, but generally when the patient needs nothing more than stretching and strengthening, and it can be done on their own, they no longer need to go. These days, of course, all insurance providers limit the number of PT sessions permitted, and they never seem to allow enough. That’s why the home e­ xercise program is so important. The patient needs to be admonished that when PT is stopped, the onus is on them to continue their exercises to get the best possible result. I tell them that they should plan to exercise their shoulder muscles the rest of their lives. When should your patient return to work? Of course, it depends on their profession. I had my surgery on a ­Friday and was in the office seeing patients on the following ­Monday. I was able to sit at my desk and type on a computer with my arm in my sling. At 10 days, I was able to do simple handsurgery cases keeping my arm at my side, and I returned to bigger cases requiring reaching at 4 weeks.

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Patients with desk jobs will be able to return as soon as they are off narcotics during the day and feel comfortable enough to get to work. That’s usually 3 to 7 days for most people. Patients who perform manual labor will need to wait until the soft tissues are healed and they have their strength back. Those who work overhead will need both strength and endurance. While patients and employers will often pressure you for a specific return-to-work date, the best you can do is to give them an estimate, but warn both the patient and employer that it is nothing more than an estimate. You’ll both be sorry if you make promises. Your patient’s return to sports can also be difficult to estimate, depending on the individual and the sport. Just as with their work, the best you can do is to give them an estimate. Let them know your estimate is at best only an educated guess. During this period, most patients are improving and getting back to their normal lives. But they’re still not perfect.

Long-Term Postoperative Period (More Than 6 Months) As mentioned previously, I noticed improvement after my surgery for over 2 years (Fig. 25-3). Early on, each month is significantly better than the month before. However after the first 6 months or so, the increments of improvement get smaller. Patients find they’re able to reach a little farther, lift a little more, and do a little more with a little less pain. Then one day they realize that it doesn’t hurt anymore when they sleep. Sometimes the patient gets completely better with full motion, strength, and resolution of their pain. They are able to perform all activities as they used to, their problem is gone, and their surgeon is a genius. Wouldn’t it be nice if that happened every time? Unfortunately it doesn’t.

FIGURE 25-3.  My MRI 18 months postoperatively showing excellent healing of the defect.

Even the good or great results are not really perfect. The surgery may have been done masterfully, with complete healing of the pathology and a perfect rehabilitation, but the patient may still have issues. Sometimes they’re minor, sometimes not. Some patients will thank you just because you took most of their pain away even though their function is not perfect, while others will complain about the slightest loss of motion or about any inkling of discomfort. Much of this goes back to the patient’s expectations and your preoperative discussion. If the patient understands ahead of time that you will not be recreating the shoulder God gave them when they were born, they will have more realistic expectations about what their final result will be. You need to explain to them not only the success rate, but also what the word success means. They might still always have some discomfort, some stiffness, or a little weakness. They will have wounds that will be visible when wearing a bathing suit. There may be certain activities that they used to do that they might not be able to return to after the surgery, even with a good result. The clearer this is made up front, the less disappointment there will be when they’re done. One thing I tell them is that we don’t have new parts to replace the damaged ones and that nature can heal but not recreate new tissues. Communicating the progress and results with your patient is extremely important, but not every surgery or postoperative course goes smoothly. What happens if the results are not good?

c FAILED SURGERIES—DOC, DID YOU MAKE A MISTAKE? No one is perfect. And no surgeon is perfect. Sometimes a mistake is made. Sometimes things go wrong without a mistake. It can happen in surgery or it can happen in rehab. It happens to every physician in every practice. The key is addressing the problem prudently and, again, communicating. The incidence of anesthetic complications, infections, pulmonary embolism, compartment syndrome, and neurovascular injuries is thankfully low after shoulder arthroscopy. More commonly, early complications like loose anchors, tissue re-tears, or stiffness can occur. Later complications like tissue re-tears and recurrent dislocations may indicate a failed surgery. It’s important for the patient to understand that even when an operation works perfectly, if they have a significant postoperative trauma, especially in the first 6 months after surgery, the repair will likely not be mature and it can fail as a result. How do you address these bad outcomes with your patients? Again, communicate. It’s a difficult situation. It’s hard for any doctor to tell a patient that the work they did failed. And it’s hard for the patient to hear that all they went through, the surgery and the recovery, were all for naught. It’s hard for them to hear that they will have to go through it all again. Whether it’s an entire redo of the first surgery, a bigger surgery, or just a manipulation, it’s an extremely difficult situation for your patient. But it’s for this reason that you need to make sure you take all the time you need to sit with the patient, look into their eyes when you’re speaking, explain the situation as clearly as possible, again with the

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x-rays, MRI, models, diagrams, and then listen to the patient and answer all of their questions. They will be confused, but if you don’t spend the time to explain everything, they will likely be angry. It will make matters worse if you don’t ­explain what failed and what needs to be done to correct the problem. And it’s okay to use the word “sorry.” It doesn’t mean you’re admitting any fault. You are telling the patient you’re sorry for them—you’re sympathetic that their result was not good. At this point, the patient will likely just proceed with the redo surgery with you. But sometimes they may want to think about it. They may want to get another opinion. Again, I don’t think second opinions should be discouraged—but it’s nice to know if they do see another doctor. After the patient leaves the office, if they haven’t scheduled the second surgery right away, I will call them to see whether they had any more questions after leaving the office and what they plan to do. You’re also showing the patient that you sincerely care about their condition and want them to get better— you’re not avoiding the problem. Knowing that their doctor cares will also lessen the likelihood of litigation. Are complications the only thing that can go wrong?

c WHEN OTHER THINGS GO WRONG: MY DOCTOR IS A POMPOUS JERK! Patient–Physician Arguments: My Surgeon and His Office Are Awful Did I mention yet how important communication is? Despite your best efforts, disagreements will still occur. Noncompliance: Most of the time, patients know they’re noncompliant. They won’t wear their sling when they are supposed to or will not do their exercises. However, sometimes they didn’t understand their instructions or don’t remember being told what to do, and they blame you or your staff. Rather than get into an argument, the best you can do is to try to move forward. Apologize to them that there was some misunderstanding or miscommunication and reinstruct or redirect the patient. Then you and your team should be more careful that it doesn’t happen again. Payment: All of our practices are structured differently and, likewise, we have different office personnel that handle patient finances. When it comes to the physician–patient relationship, it’s best to keep money out of it. I explain to the patient that my specialty is surgery and patient care. I find medical insurance issues too complicated to understand, and we have other people in the office who specialize in handling the monetary issues. I get involved only as a last resort when deciding to write off a balance or give a discount. But I will say this: it’s usually best to write off the balance on a patient who has been a problem for any reason. You’re not admitting any fault to them. You’re just avoiding adding fuel to their fire. Clashing personalities: Although I touched upon this earlier, it bears revisiting here. Sometimes, you know right away that you’re not going to get along with a patient, but sometimes, you don’t figure it out until after you’ve done surgery on them. Sometimes, their personality just changes,

or the true personality they were suppressing now comes out. Now that you’ve treated them, it may be more difficult or awkward to transfer their care. I think that in such a situation you need to really try to work things out. Try to have your staff communicate with their family member. (I had a patient who wouldn’t speak to my secretary or me—he’d only speak to my PA!) See them back again the following week to see whether things are different. Maybe they were just having a bad day. But if despite all efforts they continue to be difficult to deal with, I’d try to transfer their care to a colleague.

Litigation: I’m Calling My Lawyer! We all know that in this country anyone can sue anyone else for anything. However, it doesn’t mean they have to. Some patients may have a legitimate reason to sue their physician, but choose not to. Many don’t have a legitimate reason, but sue anyway. Regardless, there are two situations you could encounter: patients who want to sue another doctor and, hopefully less often, patients who want to sue you. Of course, any section about attorneys necessitates a disclaimer: I’m not an attorney and nothing I say here should be construed as (or confused with) legal advice. Fortunately, I can say that I actually have little experience on this topic. My only malpractice suit was over fat atrophy (which had already resolved by the time of arbitration) from a steroid injection—though I must say that, as simple and as straightforward as that case was, it was still 3 days of emotional torture. Despite my lack of experience, here are a few commonsense recommendations. Lawsuit against you: It’s never a good day when you get that letter of intent to sue. Naturally, you need to notify your malpractice carrier immediately. You may want to review the chart, but, in case you didn’t already know it, it’s illegal to change anything in the medical record, and doing so will only hurt your case later. Many of these cases will go away as the patient’s attorney figures out that it is worthless, but some don’t and will either be settled or go to trial. It’s a terribly difficult situation, and doctors react differently. Some physicians will be so angry that they’ll kick their dog, lose sleep, and project their anger on their family and staff. For others, it will bounce right off them and they will take it in stride. Just know that you can’t be a surgeon, do the kind of work you do, have the responsibility you have through all of the years that you practice, and not have an occasional adverse outcome on a patient that will litigate. It generally happens to everyone at least once in his or her practice, and you will get through it as everyone has before you. Just be compliant with your attorney’s recommendations, take a deep breath, and it will eventually be over. As they say, it’s one of the unfortunate costs of ­being a doctor. Lawsuit against first doctor: Although it’s better than you being sued, it’s still not exactly a warm and fuzzy feeling when another doctor in the community is sued, whether you like them or not. But here’s a common scenario: another doctor did the first surgery, the patient for whatever reason was not happy, and they’re either suing or thinking about suing the first doctor. Now the patient is seeing you either for continued treatment or just because they want your opinion on what the first doctor did, or both.

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Be careful. The patient may be expecting or wanting you to say that the first doctor made a mistake. You may want to say it because it makes you feel good. It’s a natural reaction for many people to elevate themselves by pointing out the mistakes of others. Maybe that other doctor once did it to you and this is your chance to get back at him. Maybe you can put yourself above all that. The patient’s attorney may want to speak to you. They may want you to write letters commenting on prior treatment. They may want you to testify on standard of care at trial. My goal here is not to tell you what to do. That’s obviously entirely up to you. My aim simply is to heighten your awareness of the situation, to help you realize that you need to be careful about what you say and what you do. There may be unintentional consequences to your words, chart notes, and actions. The patient who is looking for you to badmouth the other doctor may twist your words. Sometimes, the patient won’t really even listen to what you say and only hear what they want to hear about how the other doctor did something wrong. A safe approach may be for you to tell the patient that, as you weren’t the initial doctor and were not there for the surgery, you can’t comment on what happened. You can only comment on the current situation and make recommendations on what should be done going forward. If the case does go to trial, the patient’s attorney may ask you to testify. Again, it’s up to you, but know that there are two types of testimony: you can be retained as an expert on the issue of malpractice or you may be retained as a witness

as a treating physician. In the latter situation, you only need to testify on your treatment of the patient without having to comment on the quality of care given by the first doctor. When in doubt, it doesn’t hurt to contact your own malpractice company for legal advice.

c SUMMARY We all know the patient has feelings. We all know they need to be informed. But it happens to everyone. It’s human nature. You get into a routine. It’s the way you’ve been doing things for a long time. But for those people you’re treating, it’s not routine. For them, it’s a completely new and often frightening experience. Everything needs to be explained, and what will happen to them needs to be communicated. We all know this. It’s common sense. You, as a shoulder surgeon, knew it before reading this chapter, and I knew it before my own shoulder surgery. It turns out that I know it a lot better now. Having gone through shoulder surgery myself really made me think more deeply about every aspect of the process from the patient’s point of view. It’s allowed me to better inform my patients and help them to anticipate what they can expect during and after the operation. It’s my hope that after reading this chapter, you too will have learned about the patient’s perspective of shoulder ­arthroscopy without having to go through it yourself.

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26

Postoperative Protocols— Physical Therapy c INTRODUCTION

c HISTOLOGIC HEALING

For the shoulder surgeon, physical therapy is an important adjunct to a successful surgical outcome. However, it is an often neglected aspect of shoulder surgery for the busy orthopedist for a number of reasons. These include a frequent lack of formal training in physical therapy, a difference in technical language and perspective between the two fields, and practically speaking, time constraints. It is difficult for a busy surgeon to stay abreast on orthopedic surgery, run a practice, and stay current with the nuances of physical therapy. However, to truly optimize a successful surgical shoulder outcome, it is critical to have a working knowledge of the rehabilitation process for clear communication between the disciplines. Initiating appropriate passive range of motion (PROM) at the right time can help prevent complications such as stiffness. Examining the postoperative shoulder and having clear indications for intervention in light of the typical timeline of healing will aid in optimal therapy and functional outcomes. Our goal in this chapter is to make therapy applicable and practical for the busy shoulder surgeon. To do this, we will review the histologic healing timeline and discuss the clinical indications for advancing therapy. More specifically, we will apply the healing timeline in regard to the rotator cuff first, capsulolabral surgery second and subsequently to non-glenohumeral pathologies. The subsequent sections will review when and how to intervene with the appropriate phase of therapy during the postoperative period. We have also included a number of simple exercises in video format that can be distributed to patients after shoulder surgery.

Soft tissue healing to bone is typically divided into three phases after surgery—inflammatory phase, proliferative phase, and remodeling phase (1). It is important to know the general timeline of healing as it guides when to initiate the next phase of therapy, that is, active motion or strengthening for a rotator cuff repair should be initiated only after the tendon has healed sufficiently (2,3). Overzealous activity or strengthening too soon may result in re-tear and failure of a repair (2,3). During the initial inflammatory phase, which takes place during the few weeks after surgery, inflammatory cells populate the repair site to initiate healing. This includes fibroblasts and blood vessel formation. The second phase, or proliferative phase, quickly follows as the fibroblasts proliferate during the initial 4 weeks with fibrovascular granulation tissue and matrix deposition (1,4). Extracellular collagen is laid down. After these first 4 weeks of early healing, scar tissue reorganizes with collagen turnover. Matrix organization occurs according to tensile stresses during the third phase of healing, or the remodeling phase (4). Collagen content increases (5), and the tendon becomes less cellular (6). However, maximal tensile strength is not achieved until 6 to 26 weeks after surgery, and is quite variable (3,5,7–9). On average, 3 to 4 months after surgical repair is a reasonable point for a repair to be mature and be considered for strengthening. However, in many animal studies, the tendon biomechanical properties improve with time but may never recover full tensile strength by the study end point (5–7). In other words, allowing strengthening for a mature tendon repair is variable and should not be thought to routinely occur at a certain time point.

The SCOI editors would like to thank Marc Mirisch for his contribution on this chapter and the related videos. 379

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c CLINICAL ULTRASOUND HEALING This general healing timeline seems to be supported by ultrasound data for human rotator cuff healing. When a single-row, medialized, triple-loaded suture anchor repair was performed on various-sized rotator cuff tears, postoperative ultrasound data revealed that a mature, healed tendon depended on the size of the tear. Postoperative ultrasound data was performed at 6 weeks, 3 months, and 6 months after repair by a single surgeon. Small tears (