OPERATION:
- Right shoulder arthroscopy with mini open rotator cuff repair.
- Arthroscopic subacromial decompression.
- Arthroscopic distal clavicular excision.
- Arthroscopic superior labral debridement.
INDICATION FOR PROCEDURE: The patient is a (XX)-year-old gentleman who has a high-grade partial thickness rotator cuff tear in the right shoulder. Due to failure of conservative care, he has elected to proceed with arthroscopic evaluation with rotator cuff repair. The procedure, risks and benefits of this procedure were thoroughly explained to him and all of his questions were answered.
PREOPERATIVE DIAGNOSES:
- High-grade partial thickness rotator cuff tear, right shoulder.
- Impingement syndrome with bursitis.
POSTOPERATIVE DIAGNOSES:
- High-grade partial thickness articular-sided rotator cuff tear within the supraspinatus tendon, right shoulder.
- Impingement syndrome with bursitis.
- AC joint arthropathy.
- Degenerative type 1 SLAP tear.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia with interscalene nerve block placed by the anesthesia team in the holding area under ultrasound guidance.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
FLUIDS: 1500 mL lactated Ringer’s.
TOURNIQUET TIME: 0.
DESCRIPTION OF PROCEDURE: The patient was brought into the operating room and placed supine on the operating room table. After infusion with adequate general endotracheal anesthesia, a preoperative dose of intravenous antibiotics was given prior to this procedure. The patient was then repositioned with special attention paid to his head and neck positioning. All bony prominences are well padded. Examination under anesthesia of the right shoulder revealed full motion with no adhesions. The right upper extremity was then prepped and draped in the usual sterile fashion.
After instillation into the joint with 30 mL of normal saline, a standard posterior port was created and the anterolateral port was created under direct visualization. A diagnostic arthroscopy was then performed. There were no loose bodies in the shoulder. The glenohumeral articulation was then actually conditioned with normal aversion. There was some redundancy and fraying of the superior ligament to the anterior labrum. This was debrided but was minimal. There was no instability or detachment of the superior labrum off the glenoid. The biceps tendon showed a little bit of hyperemia in the groove but no tearing. Subscapular was intact anteriorly. The supraspinatus showed a high-grade partial thickness articular sided tear, which was probably closer to 70% to 80% of the tendon thickness. The infraspinatus was intact posteriorly. Within the subacromial space, there is a fairly dense bursitis noted with an anterolateral spur and spur off the inferior aspect of the clavicle. There was a little narrowing there as well. There was hyperemia of the remaining cuff tissue over the tear but it did not go all the way through the bursal surface.
With the diagnostic portion of the arthroscopy completed, attention was turned towards treating the pathology through a standard anterior portal. The superior labrum was addressed first. This was accomplished with a 4.5 full radius shaver and a 90 degree VAPR wand to smooth the edges. It was done from the superior labrum into the anterior labrum. At that point, the shaver was used on the undersurface of the cuff removing all unstable flaps and torn tissue. Spinal needle was passed through this from an outside technique and 0-PDS suture used to mark the tear. At that point, the scope was switched into the subacromial space.
Through a standard lateral portal, a generous bursectomy was done arthroscopically opening the space nicely. At that point, the tear was safely visualized from the bursal surface. The undersurface of the acromion was skeletonized with 90 degrees of VAPR wand as was the distal clavicle. An acromionizer bur was then used from lateral to medial and from front to back to take the small spur off the acromion. The distal clavicle was then resected in a similar fashion, first with a coplaning type technique removing the spur on the undersurface but then bringing in the bur from the anterior portal, and using a windshield wiper type technique, the distal 8 to 10 mm of bone was completely resected opening up the joint completely. At that point, the rotator cuff was addressed.
The lateral portal was then extended to about 3 cm and deltoid split in line with its fibers. The retractors were placed. Additional bursa was removed in an open fashion. The cuff tear was easily visualized and was extended to about 2 to 2-1/2 cm in full length and was completed into the joint. The edges were debrided and a curette used to remove the tissue off the greater tuberosity. Once this was done, a single medial anchor was placed in a standard fashion with a tap and anchor placed in standard fashion. Both limbs were passed with free needles with mattress sutures. This was done after a #2 Ethibond was used to act as pull sutures. With it held in place by the physician’s assistant, both sutures were through with excellent reduction of the tendon to the bone. A second anchor was placed in the lateral tuberosity to act as a double row repair. These sutures were passed as simple sutures. The #2 Ethibond were then passed anterior and posterior to the tear providing additional stability. These were actually passed through the bone with a transosseous equivalent repair. The shoulder was brought through a full range of motion. No gapping or pulling noted.
The wound was then copiously irrigated and closure initiated. The deltoid was allowed to fall closed and was reapproximated with 0 Vicryl suture in a figure-of-eight fashion. A 2-0 Vicryl was used through the subcutaneous tissues with 3-0 Prolene used for the skin and the portals. A dry sterile dressing was applied and the patient was awakened from anesthesia and transferred to the recovery room in satisfactory condition without complications.
