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Name:
Arthroscopic Management of Supraspinatus Pasta Lesion
Description:
Arthroscopic Management of Supraspinatus Pasta Lesion
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T00H19M50S
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Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
Hello, my friends, how are you? This is me, Dr. Sergio Rowinski, from Shoulder Planet here from Sao Paulo, Brazil. And in this video, I'm showing you guys how to deal with a high grade PASTA lesion of the anterior part of the posterior superior cuff, which means the supraspinatus, arthroscopically.
So this is a very easy to understand step by step guide for you to understand which steps must be done, in a very clear rationale, in order to deal with such lesions. So please don't forget to subscribe. Leave your comment. Give your thumbs up, and let's see the video. So this is a right shoulder, and in this moment, we have just done a biceps tenodesis in the lesser tuberosity
This is the biceps that we are seeing here. Again, this is a right shoulder. We have just done the subscap fixation with an anchor on the lesser tuberosity. And this is the biceps after the tenotomy, and the fixation here on the lesser tuberosity and the biceps tenodesis. What we're seeing, here, now this is the biceps, which was, as I have said, just tenotomized and tenodesed, here in the lesser tuberosity.
Here we are seeing the humeral head and, here, this is the pasta lesion of the anterior part of the supraspinatus, which will have to be fixed. So, here, we are seeing the subscap, which was just fixed, as I just have said, this is again the long head of the biceps. So,at that moment, what we have to do is to mark the articular the pasta lesion with a prolene, together with a spinal needle,
this is what we are doing, here, and then, from the anterior portal, I'm entering with a grasper in order to put this prolene outside of the shoulder through the anterior portal. So here is the anterior portal, this is the anterior cannula, which is quite difficult to see. Again, this is the humeral head here, the biceps, after the tenotomy and the tenodesis, and this is the subscap and this is the biceps anchor, the biceps was here,
as I am pointing with the arrow, and the tenotomy, was done at this place, as I'm showing you guys. So at that time, we are leaving the articular part and we are going to the subacromial space. So now we are in the subacromial space, for you guys to understand, we are working through the lateral portal, here, and we are watching through the posterior portal.
This is the shaver, and, in these cases, where we have a big amount of inflammation, we have a lot of bursal tissue and a lot of bleeding. So now we are with the shaver, some bleeding, we have to do a big bursectomy until we find the acromion, which is a very important landmark. So this is what we are seeing here. Again, this is the shaver on the lateral portal,
this is the acromion, here we see the acromial insertion of the coraco-acromion ligament. And here this is the deltoid, after removal of the internal deltoid fascia. We have to establish a big view, and it's very important, at that moment of the surgery, not to work here, medially, because it bleeds a lot. So this is the acromion, and we must work only in this area, until we do the acromioplasty and the release of the acromion insertion of the coracoacromial ligament.
So this is what we are doing now, we are just removing some bursitis, here, below the AC joint. And after that, I'm entering with the shaver again. So this is, here, the acromial insertion of the coraco acromial ligament. We just have to create a space in order to see, and in order for us to do a good release of the acromial insertion of the coracocromial ligament. In these cases, with very small tears,
we have a lot of bursal tissue, here, just below the inferior part of the acromion, and it's very important to remove it as we start to work on the subacromial space. So it's very important to work here, just below the acromion, but we must not work here, medially, I mean, not at this moment of the surgery because it bleeds a lot. So we are creating space here, just below the acromion, and now we entered with electro cautery device.
This is a radio frequency device and we will release the acromial insertion of the coraco acromial ligament and, after that, we will do the formal acromioplasty. So this is what we are doing now, and, when we start doing this, I always like to go from lateral to medial. This is what we are doing now. This is the lateral part of the anterior part of the acromion, and this is the medial part.
And I start always from lateral to medial, as I am showing here, this is what I'm doing here, with the radiofrequency device, detaching the acromial insertion of the coracoacromial ligament. After that, as I am doing here, we are just cleaning all of the soft tissue in the antero-inferior part of the acromion because we must see the bone very clearly to do the acromioplasty.
This is what we are doing here and we have to remove all of this tissue from the acromial insertion of the coracoacromial ligament. And we can do this, as we are seeing here, with the shaver and with electro cautery device, it doesn't matter. So this is what we are seeing here. So this is a right shoulder, This is the insertion, here, of the deltoid in the very antero-lateral part, here, of the acromion.
And now we are ready to start the acromioplasty, entering with the shaver through the lateral portal. So now we are entering with the shaver. As you can see, I'm going from anterior to posterior and I start laterally, and then I go medially. So now we are doing it, from anterior to posterior, medially now, in order to turn a hooked acromion into a very flat acromion.
This is what we are doing, going from anterior to posterior, laterally, here, and medially, here. This is something that must be done very fastly, during the surgery, for us to spend time in the tendon itself, in the tendon fixation itself. So now we are seeing the acromioplasty, which was quite good, but we would have to just enhance it, in the very end of the surgery, as I'm going to show you.
So at that moment, this is something very important, the acromion is here above, and it's very, very, very important to remove all the anterior gutter and the lateral gutter of the subacromial space in order for us to see a small tear of the supraspinatus, and in order for us to have space to fix it. So, again, the acromion is here, the coracoacromial ligament was released from here, and this is the anterolateral gutter.
We will continue to remove now, and, here, where the shaver is, we are on the postero lateral gutter. Now we are working to do a full removal of the internal deltoid fascia. This is a very important step of the surgery in order for us to be able to have space to work when we put the camera in the lateral portal. So what we are seeing here, at this moment, so this is the deltoid,
so a reasonable part of the anterolateral gutter was already removed. This is the deltoid, here, but we still have to do the same thing, on the postero lateral gutter, in which we are working now. So now the shaver, with the shaver, we are removing the postero lateral gutter, which is here, and we must do it broadly, fast, but we must do it. So here we have a very pedagogical view, in which this is the anterolateral gutter, in which we can see the deltoid.
And this area, here, is the postero lateral gutter, which must be fully removed, as I have said, this is what we are doing, now, with a soft tissue shaver. We can do it with an electrocautery, too. Again, this is the postero lateral gutter. In very small tears, it's very important to do a full removal of this structure in order for us to have space to work on the subacromial space.
So this is another very pedagogical image. This is the acromion, here, and this is the, a part of the postero lateral gutter, which, as I have said, must be removed. And this is the deltoid. And it's very important, in one hand, to remove this structure, but obviously we must not detach the deltoid insertion, of course, for absolutely obvious reasons. So at that moment, I am turning my camera down in order to try to see that prolene, which was marking the tear that we have just marked.
So as I rotate externally the shoulder, now I am seeing the prolene and, here, we still have a part of the anterolateral gutter, which must be removed with the soft tissue shaver. So I am entering now, through the lateral portal. We are removing all of that part. And, at that moment, I am seeing the tear here and I am completing it, with a simple hemostatic, a straight artery forceps.
It's very easy to complete the tear, as we are seeing here, because it was a high grade tear. And then I'm entering with the shaver to start removing all the pathological tissue, and that was a right moment to put the camera on the lateral portal. So now the camera is on the lateral portal. This is a right shoulder. This is the acromion.
This is the posterior part of the body, and this is the anterior part of the body and acromion itself. And here we see the acromioplasty, which would have to be finished in the very end of the surgery. So, at that moment, it's very important to establish an antero-supero-lateral portal, as I am doing here, with the hemostatic, this is a very important portal, which help us too much in this kind of procedure.
Now I am entering with electro cautery, the radio frequency device, to gain space, so here we can see the deltoid insertion on the lateral part of the a acromion, and we must obviously not detach it, but we must create space. So I am removing all of this soft tissue below the acromion. It was here, the insertion of the coracocromial ligament. It was, as we saw, already detached, but we have to remove it all.
This is what we are doing now. So this is the remaining part of the acromial insertion of the coracoacromial ligament. Again, this is a remaining part of the antero lateral gutter, which is being seen, now, through the lateral portal. We are removing it, now, with electro cautery device. It's very important, as I just have said, to remove it all, for us to have space to work in these very small anterior tears of the postero superior cuff. At that moment, we had a little trouble with the camera, but nevertheless we were continuing the surgery.
Here we are using the shaver through the antero supero lateral portal. Here we can see the prolene which was marking the tear. A few minutes after that, a few moments after that, we fixed the camera problem, and then we would continue the procedure. So now we are seeing the tear and we had just removed all of the pathological tissue.
Now I am watching through the lateral portal and working through the antero-supero-lateral portal. Ok? I am just completing the tear and just creating a bony bed in which we will put the anchor and in which we will fix the tear. So that was a partial tear that was completed. At that moment so I am entering with a spinal needle to create a good angle and a new portal just to insert the anchor.
You can use whatever anchor you like. Metallic, absorbable. This was a 5.0 absorbable anchor. Now we are doing the steps to enter with the anchor, but it doesn't matter. It can be metallic, absorbable, that's not exactly the problem. It must be, of course, double loaded. We are doing it now, and so the anchor is now in a very good position.
This is the anterior part of the postero superior cuff and this is the posterior part of the postero superior cuff. So one suture would be here and another one here, so we can pass this with a lot of instruments. Now I am entering through the anterior portal with a bird beak and, in a retrograde fashion, I am passing one of the sutures through the anterior part. And now with ashuttling device, an expressew device
I'm doing the same part, on the infraspinatus. So at that moment we would have to tie the knots. First, we are tying the knot of the infraspinatus. We're putting a lot of compression for the tendon to heal the bony bed that we have just done. After that, we would have to cut the knot and pick up the two legs of the blue one. So now we are picking the one that was outside the tendon, and then we rotate the shoulder externally to pick the leg that was through the anterior part of the tendon, and then we are tying the knot again, putting a lot of compression in order to fix the tear.
This is something very important here. This is what we call indentation. So we must put compression here, but not exactly too much not to create a lot of vascular problems in the tendons. So we have to use compression together with care not to create vascular damage to the tendon. And now this is the final result. As we internally and externally rotate the shoulder, we can see a very good fixation of the tear.
So at that moment, I took a look on the on the purchase of the anchor, together with the tendon, with a needling device, it was absolutely stable, a lot of compression on both knots that we have just done, the anterior knot and the posterior knot, and a very good fixation. This is another thing that I really like to do. So this is the posterior part of the tendon with a lot of inflammatory tissue because of the bursa reaction.
So what I like to do is to do a low temperature ablation of the posterior part of the infraspinatus, because, in my mind, it makes a lot of sense in order to diminish the inflammatory tissue and to make the patient not only feel less pain post-operatively, but in order to make the tendon heal faster. So now we are seeing the acromioplasty through the lateral portal. We still would have to finish it.
I'm entering now with the shaver through the antero lateral portal. This is a very good way to finish the acromioplasty. So now we are finishing it, and what we can see here is a bump, which is very common in degenerative cases in which we have what we call the acromial downsloping, and it's very important to release it, too, together with the acromioplasty.
So this is what we are doing now. Here we can see the deltoid insertion on the lateral part of the acromion, which obviously was not detached. This is a very obvious but very important part of the procedure. Now we are just removing the downsloping and finishing the acromioplasty in the very antero inferior part of the acromion.
So now we are just about to finish it, just making very, very, very delicate moves to finish the acromioplasty and to treat the acromial downsloping, without damaging the deltoid insertion on the acromion. Now we are very close to the end, and that was the end of the surgery. So, my friends, I hope you liked it, a nice video showing you how to deal with a high grade pasta lesion of the supraspinatus, so don't forget.
Thumbs up subscription. Leave your comment and see you in the next video, and as I always like to say, never stop flying. That's it.
Segment:0 .
Hello, my friends, how are you? This is me, Dr. Sergio Rowinski, from Shoulder Planet here from Sao Paulo, Brazil. And in this video, I'm showing you guys how to deal with a high grade PASTA lesion of the anterior part of the posterior superior cuff, which means the supraspinatus, arthroscopically.
So this is a very easy to understand step by step guide for you to understand which steps must be done, in a very clear rationale, in order to deal with such lesions. So please don't forget to subscribe. Leave your comment. Give your thumbs up, and let's see the video. So this is a right shoulder, and in this moment, we have just done a biceps tenodesis in the lesser tuberosity
This is the biceps that we are seeing here. Again, this is a right shoulder. We have just done the subscap fixation with an anchor on the lesser tuberosity. And this is the biceps after the tenotomy, and the fixation here on the lesser tuberosity and the biceps tenodesis. What we're seeing, here, now this is the biceps, which was, as I have said, just tenotomized and tenodesed, here in the lesser tuberosity.
Here we are seeing the humeral head and, here, this is the pasta lesion of the anterior part of the supraspinatus, which will have to be fixed. So, here, we are seeing the subscap, which was just fixed, as I just have said, this is again the long head of the biceps. So,at that moment, what we have to do is to mark the articular the pasta lesion with a prolene, together with a spinal needle,
this is what we are doing, here, and then, from the anterior portal, I'm entering with a grasper in order to put this prolene outside of the shoulder through the anterior portal. So here is the anterior portal, this is the anterior cannula, which is quite difficult to see. Again, this is the humeral head here, the biceps, after the tenotomy and the tenodesis, and this is the subscap and this is the biceps anchor, the biceps was here,
as I am pointing with the arrow, and the tenotomy, was done at this place, as I'm showing you guys. So at that time, we are leaving the articular part and we are going to the subacromial space. So now we are in the subacromial space, for you guys to understand, we are working through the lateral portal, here, and we are watching through the posterior portal.
This is the shaver, and, in these cases, where we have a big amount of inflammation, we have a lot of bursal tissue and a lot of bleeding. So now we are with the shaver, some bleeding, we have to do a big bursectomy until we find the acromion, which is a very important landmark. So this is what we are seeing here. Again, this is the shaver on the lateral portal,
this is the acromion, here we see the acromial insertion of the coraco-acromion ligament. And here this is the deltoid, after removal of the internal deltoid fascia. We have to establish a big view, and it's very important, at that moment of the surgery, not to work here, medially, because it bleeds a lot. So this is the acromion, and we must work only in this area, until we do the acromioplasty and the release of the acromion insertion of the coracoacromial ligament.
So this is what we are doing now, we are just removing some bursitis, here, below the AC joint. And after that, I'm entering with the shaver again. So this is, here, the acromial insertion of the coraco acromial ligament. We just have to create a space in order to see, and in order for us to do a good release of the acromial insertion of the coracocromial ligament. In these cases, with very small tears,
we have a lot of bursal tissue, here, just below the inferior part of the acromion, and it's very important to remove it as we start to work on the subacromial space. So it's very important to work here, just below the acromion, but we must not work here, medially, I mean, not at this moment of the surgery because it bleeds a lot. So we are creating space here, just below the acromion, and now we entered with electro cautery device.
This is a radio frequency device and we will release the acromial insertion of the coraco acromial ligament and, after that, we will do the formal acromioplasty. So this is what we are doing now, and, when we start doing this, I always like to go from lateral to medial. This is what we are doing now. This is the lateral part of the anterior part of the acromion, and this is the medial part.
And I start always from lateral to medial, as I am showing here, this is what I'm doing here, with the radiofrequency device, detaching the acromial insertion of the coracoacromial ligament. After that, as I am doing here, we are just cleaning all of the soft tissue in the antero-inferior part of the acromion because we must see the bone very clearly to do the acromioplasty.
This is what we are doing here and we have to remove all of this tissue from the acromial insertion of the coracoacromial ligament. And we can do this, as we are seeing here, with the shaver and with electro cautery device, it doesn't matter. So this is what we are seeing here. So this is a right shoulder, This is the insertion, here, of the deltoid in the very antero-lateral part, here, of the acromion.
And now we are ready to start the acromioplasty, entering with the shaver through the lateral portal. So now we are entering with the shaver. As you can see, I'm going from anterior to posterior and I start laterally, and then I go medially. So now we are doing it, from anterior to posterior, medially now, in order to turn a hooked acromion into a very flat acromion.
This is what we are doing, going from anterior to posterior, laterally, here, and medially, here. This is something that must be done very fastly, during the surgery, for us to spend time in the tendon itself, in the tendon fixation itself. So now we are seeing the acromioplasty, which was quite good, but we would have to just enhance it, in the very end of the surgery, as I'm going to show you.
So at that moment, this is something very important, the acromion is here above, and it's very, very, very important to remove all the anterior gutter and the lateral gutter of the subacromial space in order for us to see a small tear of the supraspinatus, and in order for us to have space to fix it. So, again, the acromion is here, the coracoacromial ligament was released from here, and this is the anterolateral gutter.
We will continue to remove now, and, here, where the shaver is, we are on the postero lateral gutter. Now we are working to do a full removal of the internal deltoid fascia. This is a very important step of the surgery in order for us to be able to have space to work when we put the camera in the lateral portal. So what we are seeing here, at this moment, so this is the deltoid,
so a reasonable part of the anterolateral gutter was already removed. This is the deltoid, here, but we still have to do the same thing, on the postero lateral gutter, in which we are working now. So now the shaver, with the shaver, we are removing the postero lateral gutter, which is here, and we must do it broadly, fast, but we must do it. So here we have a very pedagogical view, in which this is the anterolateral gutter, in which we can see the deltoid.
And this area, here, is the postero lateral gutter, which must be fully removed, as I have said, this is what we are doing, now, with a soft tissue shaver. We can do it with an electrocautery, too. Again, this is the postero lateral gutter. In very small tears, it's very important to do a full removal of this structure in order for us to have space to work on the subacromial space.
So this is another very pedagogical image. This is the acromion, here, and this is the, a part of the postero lateral gutter, which, as I have said, must be removed. And this is the deltoid. And it's very important, in one hand, to remove this structure, but obviously we must not detach the deltoid insertion, of course, for absolutely obvious reasons. So at that moment, I am turning my camera down in order to try to see that prolene, which was marking the tear that we have just marked.
So as I rotate externally the shoulder, now I am seeing the prolene and, here, we still have a part of the anterolateral gutter, which must be removed with the soft tissue shaver. So I am entering now, through the lateral portal. We are removing all of that part. And, at that moment, I am seeing the tear here and I am completing it, with a simple hemostatic, a straight artery forceps.
It's very easy to complete the tear, as we are seeing here, because it was a high grade tear. And then I'm entering with the shaver to start removing all the pathological tissue, and that was a right moment to put the camera on the lateral portal. So now the camera is on the lateral portal. This is a right shoulder. This is the acromion.
This is the posterior part of the body, and this is the anterior part of the body and acromion itself. And here we see the acromioplasty, which would have to be finished in the very end of the surgery. So, at that moment, it's very important to establish an antero-supero-lateral portal, as I am doing here, with the hemostatic, this is a very important portal, which help us too much in this kind of procedure.
Now I am entering with electro cautery, the radio frequency device, to gain space, so here we can see the deltoid insertion on the lateral part of the a acromion, and we must obviously not detach it, but we must create space. So I am removing all of this soft tissue below the acromion. It was here, the insertion of the coracocromial ligament. It was, as we saw, already detached, but we have to remove it all.
This is what we are doing now. So this is the remaining part of the acromial insertion of the coracoacromial ligament. Again, this is a remaining part of the antero lateral gutter, which is being seen, now, through the lateral portal. We are removing it, now, with electro cautery device. It's very important, as I just have said, to remove it all, for us to have space to work in these very small anterior tears of the postero superior cuff. At that moment, we had a little trouble with the camera, but nevertheless we were continuing the surgery.
Here we are using the shaver through the antero supero lateral portal. Here we can see the prolene which was marking the tear. A few minutes after that, a few moments after that, we fixed the camera problem, and then we would continue the procedure. So now we are seeing the tear and we had just removed all of the pathological tissue.
Now I am watching through the lateral portal and working through the antero-supero-lateral portal. Ok? I am just completing the tear and just creating a bony bed in which we will put the anchor and in which we will fix the tear. So that was a partial tear that was completed. At that moment so I am entering with a spinal needle to create a good angle and a new portal just to insert the anchor.
You can use whatever anchor you like. Metallic, absorbable. This was a 5.0 absorbable anchor. Now we are doing the steps to enter with the anchor, but it doesn't matter. It can be metallic, absorbable, that's not exactly the problem. It must be, of course, double loaded. We are doing it now, and so the anchor is now in a very good position.
This is the anterior part of the postero superior cuff and this is the posterior part of the postero superior cuff. So one suture would be here and another one here, so we can pass this with a lot of instruments. Now I am entering through the anterior portal with a bird beak and, in a retrograde fashion, I am passing one of the sutures through the anterior part. And now with ashuttling device, an expressew device
I'm doing the same part, on the infraspinatus. So at that moment we would have to tie the knots. First, we are tying the knot of the infraspinatus. We're putting a lot of compression for the tendon to heal the bony bed that we have just done. After that, we would have to cut the knot and pick up the two legs of the blue one. So now we are picking the one that was outside the tendon, and then we rotate the shoulder externally to pick the leg that was through the anterior part of the tendon, and then we are tying the knot again, putting a lot of compression in order to fix the tear.
This is something very important here. This is what we call indentation. So we must put compression here, but not exactly too much not to create a lot of vascular problems in the tendons. So we have to use compression together with care not to create vascular damage to the tendon. And now this is the final result. As we internally and externally rotate the shoulder, we can see a very good fixation of the tear.
So at that moment, I took a look on the on the purchase of the anchor, together with the tendon, with a needling device, it was absolutely stable, a lot of compression on both knots that we have just done, the anterior knot and the posterior knot, and a very good fixation. This is another thing that I really like to do. So this is the posterior part of the tendon with a lot of inflammatory tissue because of the bursa reaction.
So what I like to do is to do a low temperature ablation of the posterior part of the infraspinatus, because, in my mind, it makes a lot of sense in order to diminish the inflammatory tissue and to make the patient not only feel less pain post-operatively, but in order to make the tendon heal faster. So now we are seeing the acromioplasty through the lateral portal. We still would have to finish it.
I'm entering now with the shaver through the antero lateral portal. This is a very good way to finish the acromioplasty. So now we are finishing it, and what we can see here is a bump, which is very common in degenerative cases in which we have what we call the acromial downsloping, and it's very important to release it, too, together with the acromioplasty.
So this is what we are doing now. Here we can see the deltoid insertion on the lateral part of the acromion, which obviously was not detached. This is a very obvious but very important part of the procedure. Now we are just removing the downsloping and finishing the acromioplasty in the very antero inferior part of the acromion.
So now we are just about to finish it, just making very, very, very delicate moves to finish the acromioplasty and to treat the acromial downsloping, without damaging the deltoid insertion on the acromion. Now we are very close to the end, and that was the end of the surgery. So, my friends, I hope you liked it, a nice video showing you how to deal with a high grade pasta lesion of the supraspinatus, so don't forget.
Thumbs up subscription. Leave your comment and see you in the next video, and as I always like to say, never stop flying. That's it.
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T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
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B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus / Exits Player
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
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