PREOPERATIVE DIAGNOSIS(ES):
1. Lesser tuberosity fracture, malunion with subcoracoid
impingement.
2. Subluxating biceps tendon secondary to lesser tuberosity
fracture.
3. SLAP tear.
POSTOPERATIVE DIAGNOSIS(ES):
1. Lesser tuberosity fracture malunion with subcoracoid
impingement.
2. Subluxating biceps tendon secondary to lesser tuberosity
fracture.
3. SLAP tear.
4. Supraspinatus tear, small.
PROCEDURE(S)/OPERATION(S) PERFORMED:
1. Arthroscopic assisted biceps tenodesis.
2. Labral debridement.
3. Supraspinatus tear repair.
4. Open reduction and internal fixation of a proximal
humerus malunion.
IMPLANTS:
1. Multiple strands of #2 Arthrex FiberWire.
2. Two 5.5 Arthrex suture anchors.
3. One large Arthrex PushLock anchor.
COMPLICATIONS:
None apparent.
ANESTHESIA:
Scalene block supplemented with general anesthesia.
FLUIDS:
1000 mL crystalloid.
ESTIMATED BLOOD LOSS:
100 mL.
COMPLICATIONS:
None apparent.
PROCEDURE INDICATIONS:
Ms. X is a pleasant 62-year-old female, who had a
mechanical fall, sustaining the above injury. She had undergone
a trial of physical therapy injections, anti-inflammatories,
narcotic pain medication, pain management, but she continued to
have persistent pain. It is felt that based on exam, she was
having a subcoracoid impingement from the malunion as well as
pain from her biceps tendon. It was felt that she would benefit
from operative intervention.
SUMMARY:
After informed consent was obtained, risks and benefits were
discussed, the patient underwent a scalene block. She was then
brought back to the operating room suite, after being signed in
the preoperative holding area. She underwent general anesthesia.
She was then placed in a beach-chair position. She was then
prepped and draped in a sterile fashion. Antibiotics were
started within 30 minutes of the incision. A formal time-out was
performed. A posterior portal was made and an arthroscope was
introduced to the shoulder joint without difficulty. Diagnostic
arthroscopy was then performed. The SLAP tear was identified.
It went from the 1 o'clock to 12 o'clock position, and was
associated with some superior labral fraying. Anterior portal
was then made and the biceps was tenotomized at its base. The
stump was debrided back to its stable base. A small rotator cuff
tear was found at the anterolateral aspect of the insertion of
the supraspinatus.
The arthroscope was removed. A deltopectoral approach was then
made in order to gain access to the lesser tuberosity osteotomy.
The cephalic vein was dissected and retracted medially. The
deltoid was retracted laterally. The subacromial, subdeltoid,
and subcoracoid adhesions were then broken up with aid of gloved
finger. A partial bursectomy was then made to readily identify
the bicipital groove. The subscap malunion and the tear in the
supraspinatus tendon measuring approximately 1 cm x 1 cm. The
biceps tendon was elevated out of the groove and tenodesed with
#2 Ethibond to the pec insertion. Attention was then directed to
the malunion using a three-quarter inch curved osteotome. The
fracture site malunion was explored, one brisk blow elevated the
osteotomy fragment without difficulty. This was then elevated
and immobilized. The lateral portion of the malunion site was
then rongeured down back to a stable base and this was reduced
quite nicely using a free needle, #2 fiber wires were then
introduced to the musculotendinous junction of the subscapularis
and a Mason-Allen type stitch pattern was then used to help
mobilize the fragment. The corkscrew anchor was then placed at
the lateral border of the donor site, and a 2-0 drill bit was
then introduced into the lesser tuberosity fragment. The 2 limbs
of the suture anchor were then loaded through the lesser
tuberosity fragment like a button. The posterior rotator cuff
muscles were then identified with bringing the arm in abduction
and full internal rotation. Two #2 fiber wires were then
stitched to the musculotendinous junction of the teres minor and
infraspinatus. The lesser tuberosity fragment was then brought
down to a reduced position and the transosseous sutures were then
tied to secure the fragment. The construct was further
reinforced using a tension band technique by tying the #2
FiberWires that were through the musculotendinous junction of
both the posterior rotator cuff muscles to the sutures over the
musculotendinous junction of the subscapularis. The knots were
then buried in order to avoid irritation. Shoulder was taken
through the range of motion and the construct was deemed to be
stable. A transosseous suture was then placed in a figure-of-
eight pattern at the inferior aspect of the subscapularis in
order to further augment the construct. No gross motion was
identified. The C-arm was brought in which demonstrated anatomic
reduction and good stability of the construct. Attention was
then directed to the tear of the supraspinatus, the bony bed was
then prepared. The edges of the tendon were then trimmed back to
healthy viable tendon. One 5.5 anchor was then introduced in the
greater tuberosity. The free needle was then used to pass the sutures
through the supraspinatus tendon. One of the sutures was then
tied to perform a medial row and then brought over to the lateral
aspect of the humerus and to perform a double row repair with the
aid of a PushLock. This demonstrated excellent coverage and the
supraspinatus was then reapproximated back down to its bony
footprint. Sutures were all cut short in order to avoid non-
irritation. The wound was then copiously irrigated. Hemostasis
was achieved. The undersurface of the distal clavicle was not
impinging on the rotator cuff and she did not have symptoms
preoperatively of AC joint arthritis. It was felt this was not
the pertinent aspect of the procedure. The deltopectoral
interval was then closed with interrupted 0 Polysorb. The skin
was then closed with interrupted buried 2-0 Polysorb, which was
further reinforced by Steri-Strips and a running 3-0 Prolene.
All sponge and needle counts were correct x2. IV antibiotics
were given prior to incision. The patient was awakened and taken
to recovery room in stable condition.
1. Lesser tuberosity fracture, malunion with subcoracoid
impingement.
2. Subluxating biceps tendon secondary to lesser tuberosity
fracture.
3. SLAP tear.
POSTOPERATIVE DIAGNOSIS(ES):
1. Lesser tuberosity fracture malunion with subcoracoid
impingement.
2. Subluxating biceps tendon secondary to lesser tuberosity
fracture.
3. SLAP tear.
4. Supraspinatus tear, small.
PROCEDURE(S)/OPERATION(S) PERFORMED:
1. Arthroscopic assisted biceps tenodesis.
2. Labral debridement.
3. Supraspinatus tear repair.
4. Open reduction and internal fixation of a proximal
humerus malunion.
IMPLANTS:
1. Multiple strands of #2 Arthrex FiberWire.
2. Two 5.5 Arthrex suture anchors.
3. One large Arthrex PushLock anchor.
COMPLICATIONS:
None apparent.
ANESTHESIA:
Scalene block supplemented with general anesthesia.
FLUIDS:
1000 mL crystalloid.
ESTIMATED BLOOD LOSS:
100 mL.
COMPLICATIONS:
None apparent.
PROCEDURE INDICATIONS:
Ms. X is a pleasant 62-year-old female, who had a
mechanical fall, sustaining the above injury. She had undergone
a trial of physical therapy injections, anti-inflammatories,
narcotic pain medication, pain management, but she continued to
have persistent pain. It is felt that based on exam, she was
having a subcoracoid impingement from the malunion as well as
pain from her biceps tendon. It was felt that she would benefit
from operative intervention.
SUMMARY:
After informed consent was obtained, risks and benefits were
discussed, the patient underwent a scalene block. She was then
brought back to the operating room suite, after being signed in
the preoperative holding area. She underwent general anesthesia.
She was then placed in a beach-chair position. She was then
prepped and draped in a sterile fashion. Antibiotics were
started within 30 minutes of the incision. A formal time-out was
performed. A posterior portal was made and an arthroscope was
introduced to the shoulder joint without difficulty. Diagnostic
arthroscopy was then performed. The SLAP tear was identified.
It went from the 1 o'clock to 12 o'clock position, and was
associated with some superior labral fraying. Anterior portal
was then made and the biceps was tenotomized at its base. The
stump was debrided back to its stable base. A small rotator cuff
tear was found at the anterolateral aspect of the insertion of
the supraspinatus.
The arthroscope was removed. A deltopectoral approach was then
made in order to gain access to the lesser tuberosity osteotomy.
The cephalic vein was dissected and retracted medially. The
deltoid was retracted laterally. The subacromial, subdeltoid,
and subcoracoid adhesions were then broken up with aid of gloved
finger. A partial bursectomy was then made to readily identify
the bicipital groove. The subscap malunion and the tear in the
supraspinatus tendon measuring approximately 1 cm x 1 cm. The
biceps tendon was elevated out of the groove and tenodesed with
#2 Ethibond to the pec insertion. Attention was then directed to
the malunion using a three-quarter inch curved osteotome. The
fracture site malunion was explored, one brisk blow elevated the
osteotomy fragment without difficulty. This was then elevated
and immobilized. The lateral portion of the malunion site was
then rongeured down back to a stable base and this was reduced
quite nicely using a free needle, #2 fiber wires were then
introduced to the musculotendinous junction of the subscapularis
and a Mason-Allen type stitch pattern was then used to help
mobilize the fragment. The corkscrew anchor was then placed at
the lateral border of the donor site, and a 2-0 drill bit was
then introduced into the lesser tuberosity fragment. The 2 limbs
of the suture anchor were then loaded through the lesser
tuberosity fragment like a button. The posterior rotator cuff
muscles were then identified with bringing the arm in abduction
and full internal rotation. Two #2 fiber wires were then
stitched to the musculotendinous junction of the teres minor and
infraspinatus. The lesser tuberosity fragment was then brought
down to a reduced position and the transosseous sutures were then
tied to secure the fragment. The construct was further
reinforced using a tension band technique by tying the #2
FiberWires that were through the musculotendinous junction of
both the posterior rotator cuff muscles to the sutures over the
musculotendinous junction of the subscapularis. The knots were
then buried in order to avoid irritation. Shoulder was taken
through the range of motion and the construct was deemed to be
stable. A transosseous suture was then placed in a figure-of-
eight pattern at the inferior aspect of the subscapularis in
order to further augment the construct. No gross motion was
identified. The C-arm was brought in which demonstrated anatomic
reduction and good stability of the construct. Attention was
then directed to the tear of the supraspinatus, the bony bed was
then prepared. The edges of the tendon were then trimmed back to
healthy viable tendon. One 5.5 anchor was then introduced in the
greater tuberosity. The free needle was then used to pass the sutures
through the supraspinatus tendon. One of the sutures was then
tied to perform a medial row and then brought over to the lateral
aspect of the humerus and to perform a double row repair with the
aid of a PushLock. This demonstrated excellent coverage and the
supraspinatus was then reapproximated back down to its bony
footprint. Sutures were all cut short in order to avoid non-
irritation. The wound was then copiously irrigated. Hemostasis
was achieved. The undersurface of the distal clavicle was not
impinging on the rotator cuff and she did not have symptoms
preoperatively of AC joint arthritis. It was felt this was not
the pertinent aspect of the procedure. The deltopectoral
interval was then closed with interrupted 0 Polysorb. The skin
was then closed with interrupted buried 2-0 Polysorb, which was
further reinforced by Steri-Strips and a running 3-0 Prolene.
All sponge and needle counts were correct x2. IV antibiotics
were given prior to incision. The patient was awakened and taken
to recovery room in stable condition.
