Rockwood Adults CH34

1120

SECTION TWO • Upper Extremity

Open Anterior-Inferior Capsular Shift Preoperative Planning ✔ ✔ Open Anterior-Inferior Capsular Shift: PREOPERATIVE PLANNING CHECKLIST

and then a superior-lateral viewing portal. The camera is switched to the superior-lateral portal for most of the cases, and 6-mm can- nulas are placed in the anterior and posterior portals. Typically, percutaneous portals are used to place the anterior-inferior and posterior-inferior anchors without the need for standard cannulas. The anterior inferior and posterior working portal may need an 8-mm threaded cannula for ease of passing the suture shuttling device. Depending on the company, some curved passers will go through a 6-mm cannula and others need 8-mm cannulas.

❑❑ Modified beach chair with 45 degrees of hip flexion ❑❑ Pneumatic arm holder can be utilized, but is not necessary, padded Mayo stand can be used to hold arm as well ❑❑ Open shoulder retractors, including humeral head retractor, Koebel linked shoulder retractor ❑❑ Rasps/curettes to prepare site for suture anchor placement ❑❑ Suture anchors (double-loaded, high tensile strength sutures) ❑❑ No. 2 nonabsorbable high tensile strength sutures ❑❑ No. 1 absorbable PDS suture

OR table

Position/ positioning aids

Technique

Equipment

✔ ✔ Arthroscopic Capsular Plication : KEY SURGICAL STEPS

❑❑ Although lateral and beach chair positioning are possible, lateral position allows for greater distraction and traction of the glenohumeral joint and improved access to the inferior capsule ❑❑ Examination under anesthesia ❑❑ Ensure the location of neurovascular structures when placing percutaneous portals ❑❑ Both 6- and 8-mm threaded cannulas are used for this procedure ❑❑ Preparation of capsule with abrasion prior to placing sutures ❑❑ Glenoid rim preparation with a rasp or shaver prior to inserting suture anchors ❑❑ Place the inferior anchor low on the glenoid face ❑❑ For right shoulder, a “right’ curved passer is used for anterior capsular shift and a “left” curved passer is used for the posterior capsular shift, and vice versa for the left shoulder ❑❑ Patient is placed in a sling with abduction pillow. Standard postoperative protocol is followed The first step is to complete a diagnostic arthroscopy and eval- uate all intra-articular structures, looking for sources of pathol- ogy that correlates with the history, physical examination, and imaging. The patulous inferior capsule can be noted as the joint is easily distracted (Fig. 34-43B, patulous inferior capsule with positive “drive through” sign). After documenting this, a curved rasp is used to abrade the inferior capsule in preparation for the plication until punctate bleeding is noted when the arthroscopy flow is temporarily stopped. If the inferior labrum is intact, then a liberator is used to prepare the edge of the glenoid for suture anchor insertion. If there is a labral tear, then the liberator or CoVator is used to completely free up the labral tissue until the musculature of the underlying rotator cuff can be visualized. Double-loaded anchors are placed at the 5 and 7 o’clock posi- tions on the glenoid to grasp both bands of the IGHL. Percutaneous drilling will allow the surgeon to place the anchor down to the very inferior position of the glenoid or 6 o’clock position (Fig. 34-44A). A suture passer is used to penetrate the capsule approximately 10 mm off of the labrum (Fig. 34-44B) and then again pass again under the labrum for the second suture to advance the capsular tissue (Fig. 34-44C). Sutures are tied, ensuring that the knot stack remains off of the cartilage surface (Fig. 34-44D). Final arthroscopic capsular shift can be seen in Figure 34-44D. The patulous capsule is shifted to decrease the capsular volume. Working superiorly, more anchors are placed in a similar fashion, although if the labrum is intact, sutures can be used without the need for anchors (PDS plica- tion). Sutures can be of a permanent or absorbable material.

Positioning The patient is positioned in a modified beach chair position with approximately 45 degrees of hip flexion (Fig. 34-45). The head and neck are well secured and the contralateral arm is positioned comfortably on a support. An arm holder may be used, although it is not necessary. A padded Mayo stand can also be used to support the arm. The shoulder is prepped with surgical prep from the neck to the midline of the sternum to the nipple inferiorly, and the entire arm is prepped as well. Surgical Approach Surface anatomy to include the lateral clavicle, the acromion, and spine of the scapula and the coracoid are marked out on the skin prior to the start of the case. A 6-cm vertical incision beginning from the coracoid and extending to the axilla is used. Alternatively, a more traditional deltopectoral, oblique incision can also be used for this procedure (Fig. 34-46A). Technique ✔ ✔ Open Anterior-Inferior Capsular Shift: KEY SURGICAL STEPS ❑❑ Beach chair position with arm holder ❑❑ Examination under anesthesia ❑❑ Vertical skin incision or standard deltopectoral approach ❑❑ Subscapularis tenotomy ❑❑ Close down anterior capsular redundancy using inside-out vertical mattress suture ❑❑ Alternatively, insert suture anchors on the humeral head to close the patulous capsule

❑❑ Ensure the arm is in adequate abduction (20 to 30 degrees) and external rotation (20 to 30 degrees) when repairing the inferior and superior limbs of the capsule so the joint is not overconstrained ❑❑ Close subscapularis tenotomy with interrupted sutures ❑❑ Patient is placed in a sling with abduction pillow ❑❑ Follow standard postoperative protocol