Rockwood Adults CH34

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SECTION TWO • Upper Extremity

All patients are treated initially with a strengthening program designed to strengthen the rotator cuff musculature as well as improve scapular stabilization. Patients who continue to experience unacceptable instability are met with several times and counseled extensively on the inconsistent results of surgical treatment. They are counseled that some patients experience worsened pain after surgery and encouraged to weigh all alternatives seriously, including activity modifica- tion or even occupation modification. Patients who wish to undergo surgical intervention, and who are not voluntary dislocators and do not exhibit significant psychological or secondary gain issues, are indicated for surgery if they have failed despite one year of nonoperative treatment. For patients with anterior and inferior instability, an arthroscopic or open anterior-inferior capsular shift with a rotator interval closure can be performed if they have a sul- cus that persists in external rotation. For patients with pos- terior and inferior instability, operative treatment consists of an arthroscopic or open posterior-inferior capsular shift with a rotator interval closure for a sulcus that persists in external rotation. Finally, for patients with instability in all directions (anterior, posterior, and inferior), surgical treatment consists of an arthroscopic or open anterior/posterior with an inferior capsular shift with a rotator interval closure for a sulcus that persists in external rotation. Despite the known increased reduction in capsular volume with an open procedure over an arthroscopic one for MDI, 48 we prefer an arthroscopic approach as it offers a less severe complication profile as it is not necessary for the subscapularis to be taken down, repaired, and then heal. We prefer an arthroscopic capsular plication performed in the lateral decubitus position as it offers unparalleled access to the inferior capsule compared with the beach chair position. Patients have an examination performed while they are in the supine position after the induction of anesthesia so that both shoulders can be examined, and the results recorded. Once the bean bag has been inflated around the patient, the patient and bean bag are moved until the head is as close to the posterior-superior corner of the table as possible. This prevents the surgeon from having to extend their arms while operating and makes the operation more ergonomic to per- form. Two sets of seatbelts are used to secure the patient to the table and the ipsilateral leg is padded at the knee so the pneumatic arm holder cannot cause any inadvertent iat- rogenic injury (see Fig. 34-43A). A pneumatic arm holder is secured to either the anterior or posterior aspect of the bed according to surgeon preference and provides in-line traction. A separate paddle is placed slightly inferior to the

operative arm to provide abduction (see Fig. 34-43A). Care must be used to ensure that this is not placed too superi- orly, which would limit access of instruments through the anterior-inferior portal during surgery. The paddle must also be placed at a height that allows it to provide a vector of force that is predominantly abduction; if this is placed too low, then it will inadvertently provide more anterior trans- lation than abduction. Once this is completed, 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; no predrapes are utilized. A pneumatic arm holder is utilized to perform in-line traction and a separate abduction paddle is also used. The arm holder that we use can be covered with a sterile covering and can allow internal and external rotations of the shoulder. Along with marking out all surface anatomy of the exposed shoulder girdle, we also recommend measuring an area of 5 to 7 cm lateral to the lateral edge of the acromion and marking out the likely site of the axillary nerve to pre- vent any cannulas being placed in this zone. We typically utilize a superior-lateral viewing portal, an anterior-inferior portal, and a posterior working portal, and also percutane- ous portals that are not cannulated. We also commonly place an accessory posterior lateral portal which is approximately 2 cm inferior and 1 cm lateral to the posterolateral acro- mion. 35 The capsule is prepared with abrasion with either a rasp or lightly debriding with the shaver. A liberator is used to prepare the site of insertion and then a shaver is utilized to further prepare the edge of the glenoid. Suture anchors are then placed at the anterior-inferior and posterior-infe- rior margins of the glenoid (see Fig. 34-44A). A pinch of capsular tissue approximately 10 mm off the margin of the labrum is taken with a suture passer then passed under the labrum (see Fig. 34-45B), and knots are tied securing the capsule to the labrum (see Fig. 34-44C). We then pre- fer to work first posteriorly and then anteriorly, while view- ing through a superolateral portal. If the labrum is intact, then a PDS suture is used to secure the capsule to the intact labrum directly superior to the anteroinferior and posteroin- ferior anchors and then alternated with suture anchor fixa- tion working superiorly. This is able to be performed as an intact labrum provides similar fixation strength to a suture anchor. 185 We feel that this decreases the anchor burden as well as the nonabsorbable suture burden in the glenohu- meral joint, and also complications such as abrasion to the cartilaginous surface. When working posteriorly, the arm is positioned in slight internal rotation, and when working anteriorly, the arm is repositioned in slight external rotation, so excessive tightening of the capsule is avoided.

Postoperative Care

and hand motion. No active motion of the shoulder is allowed. Pendulum exercises are permitted, and passive forward flex- ion and external rotation to neutral are allowed to begin after 4 weeks within a painless ROM. Active ROM may begin at the 6-week mark, and then patients can progress to a strengthening

Patients are placed in a standard shoulder immobilizer. In the first 6 weeks, there is limited physical therapy and the patients are allowed to come out of the immobilizer for elbow, wrist,