DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Right shoulder recurrent dislocations.
POSTOPERATIVE DIAGNOSES:
1. Right shoulder recurrent dislocations.
2. Subscapularis tear.
3. Posterior labral tear.
4. Multidirectional capsular instability.
OPERATION PERFORMED:
1. Right shoulder arthroscopy, diagnostic.
2. Subscapularis repair.
3. Posterior labral repair.
4. Multidirectional anterior and posterior capsulorrhaphy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal tube and interscalene block.
OPERATIVE FINDINGS: Exam under anesthesia revealed anterior, posterior and inferior subluxability. Intraoperative findings revealed that there was a partial attachment tear of the subscapularis on the deep surface involving about 50% of the tendon attachment. The anterior labrum did not have a Bankart or ALPSA lesion, but it was with significant capsular redundancy.
Superiorly, there was a Buford complex with a cord like middle glenohumeral ligament and an absent anterior superior labrum. Posteriorly, there was a posterior labral tear with posterior capsular insufficiency. The superior labrum was intact. The biceps was intact. The remainder of the rotator cuff was intact. The humeral head and glenoid did not have significant traumatic changes. There was no posterior capsular or anterior capsular defect at the insertion on the humerus.
DESCRIPTION OF OPERATION: The patient was taken to the operating room where general and regional anesthesia was administered without difficulty. Intravenous antibiotics were given. The patient was carefully positioned lateral decubitus on a beanbag with foam supports and padding maintaining her spinal alignment. Venodyne stockings were applied.
The patient’s shoulder and arm were prepped and draped with chlorhexidine and alcohol and she was draped in a sterile fashion. Her arm was placed into 10 pounds of balanced suspension. Landmarks were noted. Stab incisions were made and the joint was accessed with blunt-tipped obturators without difficultly. Diagnostic arthroscopy was then symptomatically performed throughout the entire joint with the above-listed findings noted.
Based on these findings, the subscapularis tear and attachment site were debrided. The subscapularis was then repaired by utilizing a Linvatec Bio-Anchor placed into the attachment site on the lesser tuberosity. There was not good stability of the anchor as it pulled out, and therefore, we switched to an Arthrex titanium Corkscrew suture anchor loaded with a #2 FiberWire suture. This obtained excellent purchase within the bone. We then utilized the Spectrum suture passing device to place it through the subscapularis and tied it securely into place firmly reattaching the subscapularis to the footprint of the lesser tuberosity.
The posterior labrum was then repaired. We utilized a shaver and an elevator to abrade the posterior inferior labrum and capsule to stimulate cicatrix formation and stimulate a healing reaction. We placed a Linvatec Bio-Anchor at the posterior glenoid rim with excellent purchase within the bone. A Hi-Fi suture was utilized. This was passed underneath the labrum and into the capsule posteriorly and inferiorly approximately 7 to 10 mm, taking care to avoid the motor branch of the axillary nerve to the teres minor. When tensioned and tied into place, this eliminated the capsular redundancy, recreating a very tense and robust posterior inferior glenohumeral ligament. It also created a posterior labral bumper. That resulted in a repair of the posterior labrum and a posterior capsulorrhaphy.
The anterior capsule was then addressed by placing two more Linvatec Bio-Anchors in the anterior glenoid rim inferiorly and mid sagittal. Once again, the suture was passed beneath the labrum under the capsule going peripherally approximately 7 to 10 mm, taking care to avoid the axillary nerve. This resulted in a reefing of the anterior inferior glenohumeral ligament as well as eliminating the anterior capsular redundancy. We were careful not to over-tighten or to tack down the Buford complex. The capsule was, however, elevated to the level of the glenoid rim, eliminating the capsular recess. Once completed, the humeral head was noted to shift to a reduced position in the glenoid fossa.
We, therefore, irrigated out the surgical sites and carefully closed the incisions with buried subcuticular 3-0 Monocryl sutures. Sterile dressings were applied. A Donjoy UltraSling ER was applied. Estimated blood loss was minimal. Sponge and needle counts were correct. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
