DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Right shoulder massive re-tear rotator cuff, status post prior repair.
2. Right shoulder subacromial impingement with acetabularization of the acromion.
POSTOPERATIVE DIAGNOSES:
1. Right shoulder massive re-tear rotator cuff, status post prior repair.
2. Right shoulder subacromial impingement with acetabularization of the acromion.
3. Right shoulder rotator cuff arthropathy.
OPERATIONS PERFORMED:
1. Right shoulder revision mini-open rotator cuff repair of the massive rotator cuff tear.
2. Right shoulder arthroscopic subacromial decompression.
3. Right shoulder extensive debridement.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia with regional interscalene nerve block.
ANESTHESIOLOGIST: Bradford Doe, MD
INDICATIONS: The patient is a (XX)-year-old female who underwent a rotator cuff repair in the past. Since that time, she has had persistent pain and most notably persistent weakness in the right shoulder, despite continued conservative treatment following the surgery. Preoperative workup, both clinically and radiographically, including an MRI were consistent with a massive re-tear of the rotator cuff as well as a proximal high-riding humerus resulting in subacromial impingement and acetabularization of the acromion. Given her persistent pain and weakness to the point where it was interfering with her quality of life and activities of daily living, the patient elected to proceed with surgical intervention.
DESCRIPTION OF OPERATION: After obtaining informed consent and correctly identifying the patient, the patient was brought to the operating room and placed on the operating room table in the supine position. After adequate anesthesia was obtained and intravenous antibiotics were given, the patient was placed in a well-padded lateral decubitus position with the right upper extremity up. The right upper extremity was then prepped and draped in the usual sterile fashion and placed in 10 pounds of balanced suspension traction. The bony landmarks of the shoulder were then marked out. The skin 2 cm inferior and 1 cm medial to the posterolateral corner of the acromion was injected with 0.5% bupivacaine. A small stab incision was then made. The arthroscopic camera was introduced into the joint and diagnostic arthroscopy then ensued. Immediately noted was a large massive degenerative rotator cuff tear, which had retracted to the level of the glenoid. The entirety of the supraspinatus and infraspinatus tendon had avulsed off. There were significant degenerative changes of the labrum, and most notably, there were grade 3 and grade 4 changes of chondromalacia of the glenoid and humeral head articular cartilage. There were significant unstable chondral flaps in both the glenoid and humeral head.
Given these findings, decision was made to proceed with an arthroscopic debridement. A spinal needle was used for needle localization for the anterior portal. The skin was injected with 0.5% bupivacaine and small stab incisions were made. The arthroscopic shaver was introduced and the edges of the massive rotator cuff tear were debrided to freshen the edge. The arthroscopic shaver was then used to debride the degenerative changes of the anterior and superior labrum. The biceps tendon and its roots still appear to be intact. The unstable chondral flaps of cartilage on the glenohumeral head were also debrided extensively, given the advanced degree of rotator cuff arthropathy. Upon completion of this extensive debridement, the arthroscopic fluid and debris were aspirated.
The arthroscope was then inserted into the subacromial compartment. Immediately noted again was a large massive rotator cuff tear. Again, it was confirmed that it had in fact retracted to the level of the glenoid. Using an arthroscopic grasper, the anterior leaf of this massive rotator cuff tear was grasped and absolutely no mobility was appreciated of the anterior leaf. The arthroscopic grasper was then introduced anteriorly to grasp on the posterior leaf, and there was mild mobility noted with the posterior leaf to reduce it somewhat to the anterior leaf with margin convergence. Also, notable was a large subacromial spur and a downward slope consistent with the acetabularization of the acromion, as well as a very large excrescence on the greater tuberosity consistent with chronic impingement.
Given these findings, the decision was made to proceed with an arthroscopic subacromial decompression. Using arthroscopic shaver, the soft tissue and periosteum on the undersurface of the acromion was debrided to expose the anterior and lateral borders of the acromion. The coracoacromial ligament was preserved in case the rotator cuff was in fact irreparable. Then, using a 6 mm arthroscopic Vortex bur, approximately 8 mm of the large subacromial spur was excised beginning anteriorly and laterally and progressing posteriorly and medially until the undersurface of the acromion was converted to a flat type I acromion. The arthroscopic shaver was then used to again debride the bursal surface of the massive rotator cuff tear and to debride and freshen the edges of the rotator cuff. Lateral traction on the massive rotator cuff tear confirmed minimal mobility and inability with pure lateral traction on the tear to reduce to the articular margins of humeral head. Given these findings, decision was made to proceed and convert to a mini-open rotator cuff repair.
A 4 cm longitudinal incision was then made laterally near the junction of the anterior middle third of the acromion. The subcutaneous tissue was dissected down to expose the underlying deltoid fibers. The deltoid was then split along its fibers. Meticulous hemostasis was obtained using Bovie cautery. The subacromial compartment was then exposed. The bursa was debrided and excised to allow for better visualization of the underlying rotator cuff. The undersurface of the acromion was palpated to confirm conversion to a flat type I acromion. Then, using the Arthrex Scorpion suture passer, #2 FiberWire sutures were passed through the posterior leaf as traction sutures. A 0 Ethibond was passed through the anterior leaf as a traction suture, but again notably, there was no mobility of the anterior leaf.
Hypertrophic fibrotic scar tissue was released from the posterior leaf to again improve, as much as possible, excursion mobility of the posterior leaf. Then, using free #2 FiberWire, and again using the Scorpion instrument suture passer, margin convergence was performed reducing the posterior leaf anteriorly to the anterior leaf. After margin convergence was successful, it was noted that now the footprint to the greater tuberosity was more manageable. The excrescence on the greater tuberosity was debrided in preparation for the suture anchor. Given the patient’s prior rotator cuff repair, the old FiberWire sutures from her prior repair were then removed and then choosing a slightly different location at the articular margin of the greater tuberosity, a pilot hole was created for the suture anchor corresponding with the apex of the newly formed crescent tear, status post margin convergence. Then, 5.5 BioComposite Arthrex corkscrew suture anchor was chosen, in the case that her bone might be atrophied from disuse after this massive rotator cuff tear. Excellent bony purchase was noted with the BioComposite corkscrew suture anchors.
Then, one set of FiberWire sutures were passed through the posterior leaf of the rotator cuff in a horizontal mattress-type fashion using the Scorpion instrument. With the second pair emanating from the suture anchor, one limb from the second pair was passed through the posterior leaf and the other limb of this pair was then passed through the anterior leaf. All four suture limbs were then tied down appropriately as a pair, using an arthroscopic sliding locking technique, followed by 3-1/2 inches on alternating posts. The shoulder was then gently internally and externally rotated and the repair site was probed. With internal and external rotation, there was no significant gaping of the rotator cuff. The wound was then copiously irrigated and drained free of any debris. Traction was then let off of the arm, and now with the arm to the patient’s side, it was confirmed that there was no significant excess traction on the repair site with the arm lying adducted against the body.
Meticulous hemostasis was then obtained using Bovie cautery. The wound was then closed re-approximating the deltoid fibers in buried figure-of-eight stitches of 0 Vicryl. Subcutaneous tissue was then reapproximated using buried simple interrupted sutures of 2-0 Vicryl and then the skin edges were closed using a running subcuticular stitch of 4-0 Monocryl. The portals were also closed using buried 4-0 Monocryl. Steri-Strips were applied. Sterile dressings were applied. The patient tolerated the procedure well. There were no complications. All needle, sponge, and instrument counts were correct and the patient was transported stable and extubated to the postanesthesia care unit.
