Illustrated Tips & Tricks CH16

Chapter 16 Arthroscopic Subscapularis Repair

ROBERT U. HARTZLER STEPHEN S. BURKHART

Instruments and Equipment

ll 30- and 70-degree arthroscopes ll Antegrade and retrograde suture passers ll Suture anchors ll Arthroscopic pump ll Arthroscopic shaver and burr (5 mm) and electrocautery device ll Arthroscopic ring curettes and elevators (15 and 30 degrees) ll Arthroscopic cannulas ll 18-gauge spinal needles

Positioning and Operating Room Setup

ll We recommend the lateral position (Fig. 16-1A) with the patient leaning backward 20-30 degrees so that the glenohumeral joint lies horizontal and the working space in front of the shoulder remains open. • Goggles should be placed on the patient to protect the eyes, because the angle of approach to the lesser tuberosity often is very close to the face (Fig. 16-1B). ll A skilled surgical tech stands across from the surgeon (Fig. 16-2A) and manipulates the arm to improve visualization and access to critical working spaces. • The posterior lever push (Fig. 16-2B) is performed by applying a posteriorly directed force and an anteriorly directed counter force to the proximal and distal humerus, respectively. Surgical Approach and Intraoperative Diagnostic Techniques ll Subscapularis repair and arthroscopic long head of biceps (LHB) tenodesis should be done first if there is an associated posterosuperior rotator cuff tear, because anterior swelling can compromise the ability to carry out these procedures arthroscopically. ll LHB tenodesis high in the groove 1 (Chapter 17) is almost always indicated with arthroscopic subscapularis tendon repair: • Tenodesis protects the subscapularis repair from abrasion by the LHB when the medial sling is incompetent. • LHB tendon pathology (medial subluxation, partial tearing) commonly occurs with subscapu- laris tendon tears (Fig. 16-4B). ll Working anterosuperior-lateral (ASL) and anterior portals are created with an outside-in technique aided by spinal needles: • The ASL skin incision usually is located just off the anterolateral corner of the acromion (Fig. 16-3A) and should result in a perpendicular angle of approach to the proximal bicipital

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