karieb70
New
INDICATIONS FOR PROCEDURE: The patient is a 55-year-old, white female,
who injured her right shoulder, had a primary right shoulder rotator
cuff repair arthroscopic assisted over 8 months ago back in April 2017,
however, re-injured her shoulder and also had continued to smoke when
she was counseled regarding smoking cessation. Followup MRI revealed a
propagation and retear of her rotator cuff tear. It was explained to
the patient the options and alternatives. Revision surgery was
indicated. The nature of procedure was discussed with the patient, which
would be an open revision rotator cuff repair with an augmentation. The
patient was explained the importance of smoking cessation, however, the
patient continues to smoke, although she shows me that she will quit
smoking. She was explained the risks and potential complications
include, but not limited to death, infection, blood clot, fracture,
neurovascular injury, pain, stiffness, scarring, bleeding, inability to
repair, retear, reaction to the graft, failure of repair, poor outcome,
deltoid insufficiency. The patient signed informed consent.
PROCEDURE IN DETAIL: The patient was taken to the OR. Right shoulder
was identified as the correct operative extremity by the patient. This
site was signed by the surgeon. 2 g of IV Ancef given preoperatively
within 1 hour of incision. The patient received a right interscalene
block in the holding area by Anesthesiology. The patient was placed
supine on the OR table. After adequate general anesthesia obtained, the
patient's right shoulder was examined under anesthesia, had full range
of motion. No evidence of any instability. The patient was placed in a
semi-beach chair position with a spider attached. All bony prominences
were well padded. Right shoulder was then prepped and draped in a
standard sterile surgical fashion. Time-out performed indicating an
open revision right rotator cuff repair with augmentation as a correct
operative procedure. Using a standard open approach to the rotator cuff
repair starting at the just lateral to the coracoid in line with
Langer's line extending to the lateral aspect of the acromion at the mid
point between the anterior and posterior acromion, this site was
preinjected with local anesthetic. Incision was then made with the
scalpel. Thick flaps were then raised. The deltoid was then split
starting at the anterior acromion extending distally, not more distally
than 5 cm from the acromion. This was tagged with a #5 Ethibond.
Retractors were then placed. Good hemostasis obtained with the Bovie
cautery. At this time, the rotator cuff tear was identified. There was
no evidence of any biceps tendon. The rotator cuff tear appeared to
involve just the supraspinatus tendon and had a V-shaped tear and it was
nonretracted, which already of the tendon remained attached to the
greater tuberosity. All suture anchors remained in place. The sutures
were then removed, however, the suture anchor was left in place, given
that these were imbedded in bone and not prominent and would be
technically difficult to remove without significant bone loss. The
greater tuberosity was then prepared with a rongeur and preparing a bony
trough from the articular margin of the humeral head to the greater
tuberosity. At this time, a side-to-side repair was performed, given it
was a V-shaped tear and a release was performed to the coracohumeral
ligament. The rotator interval was also intact. At this time, the side-
to-side repair was done to the supraspinatus tendon with #2 FiberWire
sutures in a figure-of-eight fashion from the level of the glenoid
laterally to the greater tuberosity. At this time, a 2.8 Q-Fix was
placed at the articular margin and then these sutures were passed in a
simple fashion to the anterior and posterior leaf and again to the
anterior and posterior leaf. Another 2.8 Q-Fix suture anchor was placed
at the lateral aspect of the footprint of the greater tuberosity and
then these were passed in a horizontal mattress-type fashion, one in the
anterior leaf and then one in the posterior leaf. At this time, a
matrix HD RTI Biologics graft was then trimmed. The rotator cuff tear
appeared to be about 2 cm in width, which made a medium size tear.
Therefore, the sutures left from the anchors were then passed through
the graft in a similar type fashion and then the sutures were then tied.
The Q-Fix anchor in the more lateral aspect of the greater tuberosity.
Sutures were then tied to themselves and then an another Q-Fix anchor
was placed at the lateral aspect of the greater tuberosity distal to the
insertion of the rotator cuff insertion and then these were passed in a
simple fashion in the anterior and posterior aspect of the graft and
then these sutures were then tied to the more lateral footprint 2.8 Q-
Fix anchors. The sutures were then cut. The medial Q-Fix anchor
sutures were also cut. Secure repair was performed. The shoulder was
examined and had no evidence of any impingement. The previous
acromioplasty had already been performed. There was no active bleeding.
A previous bursectomy was also performed. Therefore, only a minimal
open bursectomy needed to be performed. There were minimal adhesions in
the subdeltoid region. These were also released. The axillary nerve
was protected with the suture and then at this time, the incision was
copiously irrigated. The deltoid was then repaired to the acromion with
#2 FiberWire sutures in a figure-of-eight fashion and the deltoid split
was closed with #2 FiberWire sutures in a figure-of-eight fashion. A
secure repair of the deltoid was performed to the acromion. The
incision was then closed with 2-0 Vicryl suture in inverted fashion and
the incision was closed with 3-0 Monocryl sutures in a subcuticular type
fashion. Steri-Strips was then applied and a sterile dressing was
applied. Right upper extremity placed in UltraSling. The patient
tolerated the procedure well and was taken to recovery room in good and
stable condition.
who injured her right shoulder, had a primary right shoulder rotator
cuff repair arthroscopic assisted over 8 months ago back in April 2017,
however, re-injured her shoulder and also had continued to smoke when
she was counseled regarding smoking cessation. Followup MRI revealed a
propagation and retear of her rotator cuff tear. It was explained to
the patient the options and alternatives. Revision surgery was
indicated. The nature of procedure was discussed with the patient, which
would be an open revision rotator cuff repair with an augmentation. The
patient was explained the importance of smoking cessation, however, the
patient continues to smoke, although she shows me that she will quit
smoking. She was explained the risks and potential complications
include, but not limited to death, infection, blood clot, fracture,
neurovascular injury, pain, stiffness, scarring, bleeding, inability to
repair, retear, reaction to the graft, failure of repair, poor outcome,
deltoid insufficiency. The patient signed informed consent.
PROCEDURE IN DETAIL: The patient was taken to the OR. Right shoulder
was identified as the correct operative extremity by the patient. This
site was signed by the surgeon. 2 g of IV Ancef given preoperatively
within 1 hour of incision. The patient received a right interscalene
block in the holding area by Anesthesiology. The patient was placed
supine on the OR table. After adequate general anesthesia obtained, the
patient's right shoulder was examined under anesthesia, had full range
of motion. No evidence of any instability. The patient was placed in a
semi-beach chair position with a spider attached. All bony prominences
were well padded. Right shoulder was then prepped and draped in a
standard sterile surgical fashion. Time-out performed indicating an
open revision right rotator cuff repair with augmentation as a correct
operative procedure. Using a standard open approach to the rotator cuff
repair starting at the just lateral to the coracoid in line with
Langer's line extending to the lateral aspect of the acromion at the mid
point between the anterior and posterior acromion, this site was
preinjected with local anesthetic. Incision was then made with the
scalpel. Thick flaps were then raised. The deltoid was then split
starting at the anterior acromion extending distally, not more distally
than 5 cm from the acromion. This was tagged with a #5 Ethibond.
Retractors were then placed. Good hemostasis obtained with the Bovie
cautery. At this time, the rotator cuff tear was identified. There was
no evidence of any biceps tendon. The rotator cuff tear appeared to
involve just the supraspinatus tendon and had a V-shaped tear and it was
nonretracted, which already of the tendon remained attached to the
greater tuberosity. All suture anchors remained in place. The sutures
were then removed, however, the suture anchor was left in place, given
that these were imbedded in bone and not prominent and would be
technically difficult to remove without significant bone loss. The
greater tuberosity was then prepared with a rongeur and preparing a bony
trough from the articular margin of the humeral head to the greater
tuberosity. At this time, a side-to-side repair was performed, given it
was a V-shaped tear and a release was performed to the coracohumeral
ligament. The rotator interval was also intact. At this time, the side-
to-side repair was done to the supraspinatus tendon with #2 FiberWire
sutures in a figure-of-eight fashion from the level of the glenoid
laterally to the greater tuberosity. At this time, a 2.8 Q-Fix was
placed at the articular margin and then these sutures were passed in a
simple fashion to the anterior and posterior leaf and again to the
anterior and posterior leaf. Another 2.8 Q-Fix suture anchor was placed
at the lateral aspect of the footprint of the greater tuberosity and
then these were passed in a horizontal mattress-type fashion, one in the
anterior leaf and then one in the posterior leaf. At this time, a
matrix HD RTI Biologics graft was then trimmed. The rotator cuff tear
appeared to be about 2 cm in width, which made a medium size tear.
Therefore, the sutures left from the anchors were then passed through
the graft in a similar type fashion and then the sutures were then tied.
The Q-Fix anchor in the more lateral aspect of the greater tuberosity.
Sutures were then tied to themselves and then an another Q-Fix anchor
was placed at the lateral aspect of the greater tuberosity distal to the
insertion of the rotator cuff insertion and then these were passed in a
simple fashion in the anterior and posterior aspect of the graft and
then these sutures were then tied to the more lateral footprint 2.8 Q-
Fix anchors. The sutures were then cut. The medial Q-Fix anchor
sutures were also cut. Secure repair was performed. The shoulder was
examined and had no evidence of any impingement. The previous
acromioplasty had already been performed. There was no active bleeding.
A previous bursectomy was also performed. Therefore, only a minimal
open bursectomy needed to be performed. There were minimal adhesions in
the subdeltoid region. These were also released. The axillary nerve
was protected with the suture and then at this time, the incision was
copiously irrigated. The deltoid was then repaired to the acromion with
#2 FiberWire sutures in a figure-of-eight fashion and the deltoid split
was closed with #2 FiberWire sutures in a figure-of-eight fashion. A
secure repair of the deltoid was performed to the acromion. The
incision was then closed with 2-0 Vicryl suture in inverted fashion and
the incision was closed with 3-0 Monocryl sutures in a subcuticular type
fashion. Steri-Strips was then applied and a sterile dressing was
applied. Right upper extremity placed in UltraSling. The patient
tolerated the procedure well and was taken to recovery room in good and
stable condition.
