With the patient positioned in beach chair decubitus, the anatomical profiles of the osseous structures are made on the skin. The arthroscope is introduced into the glenohumeral joint through a standard posterior portal. Anterior midglenoid portal is established with a taper-tipped guide rod inserted in the cannula of the scope. A thorough diagnostic arthroscopy examination is performed by positioning the arthroscope in both the anterior and posterior portals. In particular, the condition of the LHBT is evaluated to assess degeneration, tearing, and stability in the groove. The rotator cuff is also thoroughly assessed to evaluate concomitant disorders. The associated tears are evaluated in terms of size, and the retraction and mobility of the edges of the lesion are estimated. In the case of partial lesions, an intraarticular and subacromial evaluation is performed with a bursectomy and debridement of the subacromial space as necessary. This step is very important in order to facilitate the subsequent knotting procedure. With the arthroscope positioned in the posterior portal and a 5.5-mm cannula in the anterior portal, having completed the diagnostic arthroscopy and subacromial space decompression, any degenerative changes of the LHBT are debrided. Once the decision to perform tenodesis is taken, an 18-gauge spinal needle is introduced through the skin in the location of the lateral deltoid immediately adjacent to the anterior–lateral corner of the acromion. The spinal needle is then visualized under arthroscopic visualization as it penetrates through the rotator cuff (
Fig. 47.1). The route of the spinal needle within the rotator cuff could be influenced by the presence of a concurrent cuff lesion. In the presence of a partial lesion, the needle will pass through the supraspinatus tendon in the anterior preinsertion area. In the case of full-thickness lesions, however, the morphology and width of the lesion are determining factors. If the complete rupture has retracted, a useful technique is that of exerting traction on the edge of the tendon with the aid of a clamp in order to facilitate the passage through the cuff tendon. At this point, the tip of the needle is oriented toward the base of the bicipital tendon approximately 1 cm away from its glenoid origin. The better
orientation of the needle is perpendicular to the long axis of LHBT. Once the spinal needle pierces the LHBT, the shuttle relay is introduced into the needle and manually driven until it appears within the joint (Fig. 47.2). A grasping clamp introduced through the anterior portal allows the surgeon to extract the shuttle relay and then to retract the spinal needle without damaging the nylon sheath (Fig. 47.3). After having removed the needle, a no. 2 nonabsorbable suture (Fiber Wire) is loaded in the eyelet of the shuttle, taking care to avoid acute angles and subsequent damage to the surrounding tissues (Fig. 47.4A). In this way the suture is carefully drawn through the rotator cuff and the LHBT until its exit from the anterior cannula (Fig. 47.4B). At this point, one limb of the suture protrudes from the skin adjacent to the acromion and the other limb exits from the anterior cannula. At this moment the shuttle relay is released, then the same steps are repeated a second time taking care to position the needle at least 0.5 cm from the first needle route to guarantee adequate resistance of the tissues at the moment of suturing (Figs. 47.5A, B). During the second route the shuttle is retrieved and the eyelet pulled out of the anterior portal. The end of the suture limb that was pulled and protrudes through the anterior cannula is promptly tied to the eyelet of the shuttle and then pulled back through the anterior cannula, through the biceps tendon to be recuperated out of the skin (Fig. 47.6). At this point, both suture limbs protrude from the skin just lateral to the acromion and envelope the LHBT and the rotator cuff in a ‘‘U’’ shape (Fig. 47.7). A bipolar electrocautery (Arthrocare) is introduced through the anterior cannula to release the LHBT close to its insertion, while a mild tension force is applied to the sutures in order to protect them from potential damage and also to facilitate the release of the tendon. The residual stump of the LHBT is debrided to a stable margin. After bicipital release, the suture protruding from the skin is pulled taut to evaluate the final effect that can be obtained with the knotting procedure (Fig. 47.8). At this point the arm position is changed to approximately 20 degrees of abduction to open the subacromial space. The arthroscope is now inserted through the posterior portal into the subacromial space and a further arthroscopic examination is performed. Once the sutures are well visualized, they are extracted through the anterior cannula using a grabber and tied. The knot can be a sliding one or a nonsliding one, according to the degree of friction produced by the soft tissues. In order to promote adequate gliding and contact between the two tendon surfaces, we prefer to choose the posterior limb as the post. Once the knot has been tied, the operation is completed in accordance with the specific clinical situation present. In the case of partial side-to-side repair for massive rotator cuff tears, the bicipital tendon stump can be used effectively as additional tissue when the tendinous gap is very wide or the quality of the tissues is found to be poor.
Patient Positioning and Anesthesia for Rotator Cuff Surgery
Arthroscopic Trillat Procedure for Recurrent Anterior Shoulder Instability With Associated Irreparable Rotator Cuff Tear
Nonoperative Care of Rotator Cuff Disorders: Physical Therapy, Modalities, and Injectables
SLAP II Tears: Evaluation and Surgical Techniques for Fixation
Impingement Syndrome: Diagnosis and Management
Shoulder Stiffness (Adhesive Capsulitis) With A Rotator Cuff Tear: How to Manage
