Transcript Arm Positioning and Screw Placement in Massive Rotator

Arm Positioning and Screw
Placement in Massive Rotator
Cuff Tears
WILLIAM F BENNETT MD
Sarasota, Florida
Purpose
• Illustrate Arthroscopic Techniques to
Facilitatea) identification of retracted tendons
b) separation of tendon from bursae
c) separation of tendon from glenoid
d) mobilization of retracted tendons
e) arm positioning and mobilization
f) arm positioning and screw placement
g) arm positioning and suture placement
h) arm positioning and knot tying
Keep in mind that chronic retraction and fatty degeneration may
indicate a situation in which the cuff is not repairable
a) Identification of retracted
tendons
• Prior to repair it is important to identify all structures
torn
• initial visualization of tendons from glenohumeral
view can help plan the repair
• repair of all tendon tears without repair of
coracohumeral head tears may still result in
unwanted medial lateral motion of the biceps tendon
a) Identification of retracted
tendons(contd)
• In large and massive tears crescent appearance
typical from glenohumeral and subacromial view
• Individual tendons vary from mainly subscapularis
and supraspinatus to supraspinatus and infraspinatus
to subscapularis, supraspinatus and infraspinatus
• Degree of retraction varies
• Involvement of heads of the coracohumeral ligament
vary
View from
lateral portal
a) Identification of retracted
tendons cont’d
• Infraspinatus retracts not only medially but posteroinferiorly, best visualized from subacromial space
• posterior to spine of scapula
• usually is scarred into the inner fascia of the deltoid
muscle
• very important plane between infraspinatus and
posterior deltoid
• often difficult to differentiate tendon from bursae from
inner fascia of deltoid
a) Identification of retracted
tendons cont’d
• Supraspinatus often retracted to glenoid level
• can be visualized from glenohumeral and
subacromial space
• anterior to spine of scapula
• recognize that while a large crescent sign is present,
there is usually a component of longitudinal splitting
between supraspinatus and infraspinatus
• while longitudinal split may not be visible often sideto-side repair is needed to achieve coverage
a) Identification of retracted
tendons cont’d
• Subscapularis tendon can vary in its involvement
from partial thickness and length to full thickness and
length
• best visualized from glenohumeral joint with arm in
flexion and internal rotation
• the lateral head of the coracohumeral ligament must
be disrupted to have retraction of the subscapularis
tendon
• IASS may be disrupted yet subscapularis appears in
relative anatomic position
• the subscapularis tendon is involved approximately
30% in all rotator cuff tears to some degree
a) Identification of retracted
tendons cont’d
* IASS may be disrupted yet subscapularis appears
in relative anatomic position
* The subscapularis tendon is involved approximately
30% in all rotator cuff tears to some degree
* MRI findings are subtle but present with subscapularis
tears
a) Identification of retracted
tendons cont’d
• Biceps subluxation can occur with varying
combinations of rotator cuff tendon involvement
– Supraspinatus and lateral head coracohumeral
ligament
– Subscapularis and medial head coracohumeral
ligament
– Supraspinatus , subscapularis and both heads of
the coracohumeral ligament constitutes complete
disruption of the bicipital sheath
• Thus, important to identify structures from the
glenohumeral view
b) Separation of tendon from
bursae
• Posteriorly- must take judicious time to separate
infraspinatus from inner fascia of posterior deltoid
• technique requires placing a shaver with closed end
against the tendon and under direct arthroscopic
visualization sweeping the shaver downwards while
applying pressure against the infraspinatus
• in time there will be a space identified between the
infraspinatus tendon and deltoid
b) Separation of tendon from
bursae cont’d
• Final visualization will allow one to see the insertion
of the teres minor and visualize the muscle tendon
junction of the infraspinatus
• The separation must be taken inferiorly to a sufficient
level to mobilize the entire infraspinatus as it usually
is balled up and subluxed postero-inferiorly
b) Separation of tendon from
bursae cont’d
• Superiorly the supraspinatus tendon is retracted and
typically retracted to the glenoid level and anterior to
the spine
• It is contiguous with the coracohumeral ligament and
separation of the tendon from overlying bursae and
fat pads will help identify both
• separation of the tendon from the fat pad is essential
b) Separation of tendon from
bursae cont’d
• Anteriorly the subscapularis may or may not be
retracted
• Repair of partial and full thickness partial and full
length tears without retraction typically require a
portion of the body of the coracohumeral ligament to
be resected for visualization, area of the anterior
portal
• Retracted tears require the same shaver technique to
remove the subscapularis from the inner fascia of the
anterior deltoid
c) Separation of tendon from
glenoid
• Posteriorly- the infraspinatus can be separated from
the glenoid from the lateral portal with visualization
from either anterior or posterior
• keep in mind that the suprascapular nerve is not far
away
• Superiorly-hardest to mobilize any length from
anterior glenoid
• Anteriorly-lateral portal, plane between the
coracohumeral ligament and coracohumeral ligament
d) Mobilization of retracted
tendons
• Mobilization should be maximized so as not to place
the tendons under too much tension
• mobilization is more than separation
• often either a stay suture of a soft tissue grasper
helps to mobilize the tendons to the footprint of the
rotator cuff insertion
• mobilization requires that all tendons be free from
glenoid and from overlying structures
Posterior
view
Lateral
view
E) Arm positioning in
conjunction with mobilization
• Beach Chair position allows for many degrees of
freedom during the repair
• the use of a Mayo stand(elevation) aids in bringing
the arm into abduction in order to bring the arm to the
tendons rather than the tendons to the arm
• With the arm at 60-80 degrees of abduction the arm
can be internally and externally rotated to bring the
various portions of the rotator footprint to
approximation with the tendons
E) Arm positioning in
conjunction with mobilization
cont’d
• Abduction and external rotation facilitates
approximation of infraspinatus with footprint
• further abduction facilitates approximation of the
supraspinatus tendon with footprint
• abduction and internal rotation facilitates
approximation of the sleeve of the coracohumeral
ligament
E) Arm positioning in
conjunction with mobilization
cont’d
• Subscapularis mobilization and repair is best done
from the glenohumeral joint
• Often the IASS and/or MCHL is torn
• fibers often remain attached traversing to lateral
bicipital sheath
• shoulder flexion and internal rotation helps visualize
these lesions
• a soft tissue grasper through the subacromial lateral
portal can be placed through the supraspinatus
defect and this tissue reduced to proper footprint
E) Arm positioning in
conjunction with mobilization
cont’d
• Preparation of bed of bleeding bone for IASS
attachment(subscapularis) best done through
superior portal with arm in flexion and internal
rotation
• arm position for attachment should be with the arm at
side and arm held at external rotation which is equal
to opposite side
F) Arm Positioning and Screw
Placement-infraspinatus and
supraspinatus
• Screw should be inserted at 45 degrees to bone
• arm should be closer to side to facilitate proper angle
• use one 5mm corkscrew with #2 tevdek by 2 for each
centimeter of tear
• start from either far anterior or far posterior and work
away from first screw
• I use a portal directly through the skin with no
cannula placed directly anterior to the lateral
subacromial portal
• I place all screws through same hole
• Vary screw placement by movement of arm in
F) Arm Positioning and Screw
Placement-infraspinatus and
supraspinatus cont’d
• Posteriorly- first screw should be at insertion of teres
minor
• best visualization of this insertion with arm abducted
60-80 degrees and in full internal rotation
• However, screw placement may require that the arm
be brought out of abduction to achieve “dead-man”
angle
F) Arm Positioning and Screw
Placement-infraspinatus and
supraspinatus cont’d
• Place all screws at once
• through same skin incision
• proceed anterior from posterior to anterior by
externally rotating the arm in 60-80 degrees of
abduction
• often trial reduction of all tendons is necessary with
soft tissue grasper to visualize reduction
F) Arm Positioning and Screw
Placement-subscapularis
• Subscapularis screw placement is different
• Screws are placed through the anterior portal with the
scope in the glenohumeral joint
• If retracted screws go directly into the previously
prepared bed of bleeding bone
• if not retracted screws go through the tendon after
noting insertion site with trial reduction
• screw is brought through tendon and into the joint
under direct visualization and then backed out
• then the arm is brought into proper external rotation
and the insertion device is used to lever the
subscapularis into position and the screw is
advanced into the bone
g) Arm positioning and suture
placement
• Sutures nonabsorbable #2 Tevdek preferred
• tendon edges debrided to viable tissue
• passage with shuttle relay or disposable suture
retriever
• introduced through lateral portal
• retrieved through anterior portal
• then pass through limb and post brought through
lateral portal
• various combinations of Mayo stand elevation and
internal and external rotation allow for proper
placement of sutures through tendons
h) Arm positioning and knot tying
• Various combinations of Mayo stand elevation and
internal and external rotation of the shoulder allow for
knots to be tied by bringing bone to tendon rather
than having to bring tendon to footprint and hold in
place
• alternative is to mobilize the tendon to footprint and
hold in place with soft tissue grasper or by passing a
stay suture first
h) Arm positioning and knot tying
cont’d
• First knot should secure the teres minor infraspinatus
junction
• usually use two knots in close proximity
• knot is tied with arm abducted 60-80 degrees and
shoulder brought into external rotation which brings
the footprint to the posterior tendons
• proceed from posterior to anterior by incrementally
bringing the shoulder from external rotation to internal
rotation-see next slide
• sometimes it is easier to secure anterior and
posterior margins of the “crescent” then work on the
middle portion of the tear-see 2nd following slide
h) Arm positioning and knot tying
cont’d
• Side-to-side repair is facilitated by passing a free #2
Tevdek from the anterior portal through the anterior
tendons across the longitudinal split and out through
the infraspinatus tendon
• space developed between the inner fascia of the
posterior deltoid and the infraspinatus tendon will
allow for the suture to be directly visualized and
retrieved through the lateral portal
h) Arm positioning and knot tying
subscapularis
• Knots are retrieved through the superior portal and
then brought out through anterior cannula
• dual monitor helps facilitate tying by allowing the
surgeon to come to the anterior part of the shoulder
and tie directed posterior
• remember in this position the monitor image is a
mirror image and the anatomic area you are
visualizing or tying will require you to move you hand
180 degrees to the opposite side of what you think
NOTICE HOW BICEPS NOW CAN NOT BE
PULLED MEDIALWARD AFTER REPAIR
Conclusions
• Employment of these techniques will allow repair of
large and massive rotator cuff tears that might
hitherto been though not to be repairable from a
technical standpoint
• remember no matter how good the technique some
tendons may not be mobilized
• remember no matter how good the technique if
significant fatty degeneration is present in the
muscles affected that even if the “cable” can be
attached the “engine” may never fire again
• remember no matter how good the technique some
tendons have undergone chondroplastic changes
and despite reattachment may not heal
Food for Thought
• Remember (Gerber) large and massive rotator tears
with open techniques have about a 30% incidence of
some portion of the repair not healing
• patient should be informed about this and presented
with possible need for staged repair or simple force
couple repair
• Personal arthroscopic experience(clinical exam only)
using 5mm corkscrew with #2 tevdek placed one
simple suture per centimeter for
massive- about 30% non-healing of a portion
large-about 10% non-healing of a portion