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Name:
Open Cuff Repair - GT Relocation
Description:
Open Cuff Repair - GT Relocation
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/812ea7eb-a234-4195-b50c-29f03de16aef/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H27M22S
Embed URL:
https://stream.cadmore.media/player/812ea7eb-a234-4195-b50c-29f03de16aef
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/812ea7eb-a234-4195-b50c-29f03de16aef/Open Cuff Repair - GT Relocation.mp4?sv=2019-02-02&sr=c&sig=0sgY%2BRW9kPIrU89KvouN%2Fm7nC0qkbC6AAG%2BJIsNXuHs%3D&st=2024-12-04T08%3A31%3A12Z&se=2024-12-04T10%3A36%3A12Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
BIJAYENDRA SINGH: Welcome back to my channel again. Today I'm going to show an open rotator cuff repair. This is not a degenerative tear, but a traumatic tear following a fracture dislocation of the shoulder. So it's a 58-year-old man who had an unwitnessed fall, had a seizure and presented to the emergency department with an injury to his right shoulder.
BIJAYENDRA SINGH: As you can see, his initial radiographs are very poor and only took the whole of the humerus and shows the shoulder in one corner but you can easily see that is a fracture dislocation of the shoulder. As we/the checked radiographs immediately afterward showed satisfactory relocation of the shoulder. And unfortunately, because the arm is usually held in an internal rotation, you cannot assess the greater tuberosity, but it looks well placed.
BIJAYENDRA SINGH: So this is followed up at three weeks with checked radiographs, which shows a displaced fracture of the greater tuberosity, which in all supraspinatous and praspinators and is classically seen. It displaces medially. At this stage a CT scan was arranged and it also showed a small bony labral injury. Bony, bankrupt lesion. But this was managed with grateful watch.
BIJAYENDRA SINGH: I do not think that in a 58-year-old that INAUDIBLE is of much significant. My concern with related to that would be of stiffness with this kind of injury. So the CT scan does confirm there was fragments and it also shows that, that is just more than the greater tuberosity. Well, then it goes into the lesser tuberosity as well, which makes this fragment more fractured, more complex.
BIJAYENDRA SINGH: One of the worries at this stage is always the new stiffness and this patient did have a fair amount of stiffness as the procedure was further delayed because he was found to have atrial fibrillation, making the surgery another three weeks delay. So this procedure is being done at about seven weeks from the original injury. I sometimes undertake the manipulation to restore some movement and some of the releases are done [INAUDIBLE] as we will see.
BIJAYENDRA SINGH: Just showing the draping on the shoulder. Great blue, everything. MUSIC PLAYS/VOICES INTERSPOSED] Full color. Yeah Christmas tree. Christmas tree. Can I just stand in my window then with the lights on and tell my kids, this is the Christmas Light for this year. [MUSIC STOPS]
BIJAYENDRA SINGH: At this stage I then mark the incision. I always mark my landmarks, the acromion, the AC joint, and then draw my incision, which is along the deltoid split about a centimeter behind the interior of the acromion.
BIJAYENDRA SINGH: About ten, twelve centimeters long incision. You usually draw a line at about 7cm roughly where the auxiliary nerve is going to be from the tip of the acromion. Then start my incision. All my incisions have 1% xylocaine with adrenaline and it's injected into the plane which provides a good initial hemostasis.
BIJAYENDRA SINGH: Thick flaps are raised.
BIJAYENDRA SINGH: Now marking the acromion and about 6 to 7 centimeters again, this is just for the purpose of the video. And at this stage, I will put a stay stitch just proximal to where I think the axillary nerve is going to be, taking full thickness of the deltoid and just laying a suture and it's important to put this stitch right in the center of where the split is going to be so that you don't accidentally go further into the axilliary nerve.
BIJAYENDRA SINGH: I then release the deltoid, leaving about four or 5 millimeter of the anterior chromium and taking full thickness of the fascia. And I'll incise with the diathermine for about two-three centimeters distally then I lift off the deltoid from the chromial fascia to facilitate my acromioplasty.
BIJAYENDRA SINGH: Once I've done this bit. I will then go into the deltoid muscle, using scissors and doing dissecting and making sure I go right up to the edge of the lateral edge of the acromion. And I know it is quite safe to dissect distally. So I will go until my stay stitch because that's the safe territory making sure I do full thickness really or solve a small self retainer.
BIJAYENDRA SINGH: At this stage, especially in these traumatic cases, the bursa has become quite thick. Because of the haematoma and the bursa is normally thick anyway. You need to make sure that you take off enough bursa. This is my osteotomy to release the deltoid and doing my acromioplasty remove about four to 5 millimeters off of the chromium and this bone then I use it as a graft in the defect.
BIJAYENDRA SINGH: I make sure I've gone right up to the edge of the ACJ with my release, and then you start to release your deltoid. So this is just showing my system, the only sliver that I take off is the deltoid, which facilitates better healing as it's a bone to bone. Further dissecting the deltoid up to my split, I then feel INAUDIBLE, as I would normally do for a filus, running my finger from the posterior aspect to just feel it,
BIJAYENDRA SINGH: I do not isolate it for this procedure. I feel there is no point in doing a very minimal approach as once you take in the deltoid or from the acromion, however long you split it, the healing is still the same and by doing an adequate. I'm trying to isolate and find the greater tuberosity fragment as this is already six weeks
BIJAYENDRA SINGH: there is some fibrous healing that has happened. I feel for the movement of the fragment under the deltoid, just identifying the plane. Where to go would often release the rotated interval and make a split in the rotator cuff to achieve two things. One is to identify the fragment, and also it helps mobilize the rotator cuff.
BIJAYENDRA SINGH: So you can see here, I've managed to locate my bony fragment. So I'm going to next split the rotator cuff both round the front and the back to facilitate mobilisation and tension free repair.
BIJAYENDRA SINGH: So you can see there's still quite an extensive bursa that needs to be debrided and removed for us to be able to identify the rotator cuff easily. Now using a heavier pair of scissors quite gently mobilize the fragment from the bone base and then going anteriorly first into the rotator interval and make a split in the cuff.
BIJAYENDRA SINGH: Once I have done that, then you can start to see the humeral head underneath, I'm also going posteriorly to do, like a posterial triball slide. You can see the humeral head just sitting under the tuberosity fragment, as you can see at this stage the fragment is still not very mobile and I will need to do some more releases, although I can bring it back, it feels quite tight.
BIJAYENDRA SINGH: So at this stage what I would do is do the release further in the rotated interval. Also do a subdeltoid release preparing for the repair. Use a 5.5 millimeter swivel lock anchors. Generally put one, maybe two fiber wire with the needle into the anchor, the first anchor is going to go posterior insert, putting two sutures through there.
BIJAYENDRA SINGH: This is inserted just under the posterior edge of the, under the articular surface. Remember, the additional central holding suture can be used as well to pass through the rotator cuff.
BIJAYENDRA SINGH: My nurse is asking me, why do not I use the tap here and she had kept it open? But because the bone is soft, you can just use the anchor straight away, although they're non self punching. This is the second anchor with one suture going in the anterior part of the humeral head.
BIJAYENDRA SINGH: Once the sutures are in, then you start to pass the fiber wire suture through the anchor. I've developed this technique over a number of years, as I used to find sometimes passing the sutures through the cuff can be challenging, but a little bit of perseverance does work. It's important to remember that the strength of your repair is proportional to the number of passes through the sutures
BIJAYENDRA SINGH: through the rotator cuff. I often will incorporate the biceps long head if it is present as this reduces the chances of patient developing signs from biceps irritation and also improves the strength of the repair.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: Once I'm satisfied with the number of passes that have been undertaken I just try and see if I can reduce the one fragment to its place without putting too much pressure onto the tendon itself as otherwise, they're likely to fail. I'd like to provide a tension free repair.
BIJAYENDRA SINGH: The stay, then cleared out at the top of the humerus before I start making some drill holes for my button plate normally use a 1.6 millimeter k-wire, or you could use a drill bit of a similar size. And I use a Houston suture passer or you could use a PDS. Loop through, pull the sutures that have been put through the cuff
BIJAYENDRA SINGH: Into the, in to the humerus. Generally make about 4 to 6 holes in the upper end of humerus, depending on the spread of the sutures.
BIJAYENDRA SINGH: Make sure that the drill holes are spread around otherwise they are likely to cause crack in the upper end of the humerus.
BIJAYENDRA SINGH: Once I've made my passes, then I use this button plate which has got multiple holes. This acts as a bridge over the humerus and reduces the stress on the humerus, stopping it from cutting through the upper end of the humerus as this is generally becomes a bit softer even in the younger patients because of the immobility and the injury.
BIJAYENDRA SINGH: These holes are fairly wide spread so you can spread the sutures across. Once I've done that, I'll lay this flush to the upper end of the humerus, reduce the bony fragments. You can see on the top and
BIJAYENDRA SINGH: then start to tie the sutures. So I would hold the button with forceps and then start to tie from one end making sure that you remove all the slack in the sutures otherwise they will come loose and the tuberosity fragment is likely to migrate.
BIJAYENDRA SINGH: And see, that's a good positioning. I'll often get my assistant to do the knot tying whilst I hold the button plate in place.
BIJAYENDRA SINGH: At the end then I take another epibond suture or a fiber wire suture and do a run through stitch to close any of the gaps. I'll also do a thorough closure of the rotator interval. This does increase the risk of slight stiffness, but it provides a better and a robust repair.
BIJAYENDRA SINGH: And I'm happy to come back and deal with the stiffness at a later date if it's required but I'd rather have a strong repair to begin with.
BIJAYENDRA SINGH: These are the final pictures before closure. I always advise to take as many pictures on table as you wish and different rotation as this is the best chance To get views that the surgeons like. After this, I close the deltoid using Transocean suture with non absorbable suture material going through the deltoid, the front and the rest of the acromion.
BIJAYENDRA SINGH: If the patient is very young and has got hard bone, sometimes you may need to use a k-wire or a drill bit of 2 millimeters to starter from the cortex but most of the time the needle is strong enough to go through that, do a mattress repair at the top. And then close the rest of the deltoid using an absorbable suture as shown on my video of proximal humerus repair.
BIJAYENDRA SINGH: Use the bone removed from the acromioplasty and insert it where the gap is. If required, you can also supplement it with additional bone putty, or phone chips. The wound is closed in layers. I generally use a particular monocle for the skin. A pressure dressing is applied and the arm is placed in a sling. Get the patient doing pendulum exercises as soon as tolerable, usually after 24 hours
BIJAYENDRA SINGH: or once the block has worn off. We start active assisted at about two weeks and active movements in four weeks. Grade the physio with focusing on forward flexion and external rotation in the early phases and the abduction comes later on. I expect to get full passive movement by about three months.
BIJAYENDRA SINGH: And if the patient is still struggling, then consider a glenohumeral joint release hydrodynamic notation that stage. Thank you for watching the video. For more information or videos, please visit my YouTube channel or contact via my Secretary.
Segment:0 .
BIJAYENDRA SINGH: Welcome back to my channel again. Today I'm going to show an open rotator cuff repair. This is not a degenerative tear, but a traumatic tear following a fracture dislocation of the shoulder. So it's a 58-year-old man who had an unwitnessed fall, had a seizure and presented to the emergency department with an injury to his right shoulder.
BIJAYENDRA SINGH: As you can see, his initial radiographs are very poor and only took the whole of the humerus and shows the shoulder in one corner but you can easily see that is a fracture dislocation of the shoulder. As we/the checked radiographs immediately afterward showed satisfactory relocation of the shoulder. And unfortunately, because the arm is usually held in an internal rotation, you cannot assess the greater tuberosity, but it looks well placed.
BIJAYENDRA SINGH: So this is followed up at three weeks with checked radiographs, which shows a displaced fracture of the greater tuberosity, which in all supraspinatous and praspinators and is classically seen. It displaces medially. At this stage a CT scan was arranged and it also showed a small bony labral injury. Bony, bankrupt lesion. But this was managed with grateful watch.
BIJAYENDRA SINGH: I do not think that in a 58-year-old that INAUDIBLE is of much significant. My concern with related to that would be of stiffness with this kind of injury. So the CT scan does confirm there was fragments and it also shows that, that is just more than the greater tuberosity. Well, then it goes into the lesser tuberosity as well, which makes this fragment more fractured, more complex.
BIJAYENDRA SINGH: One of the worries at this stage is always the new stiffness and this patient did have a fair amount of stiffness as the procedure was further delayed because he was found to have atrial fibrillation, making the surgery another three weeks delay. So this procedure is being done at about seven weeks from the original injury. I sometimes undertake the manipulation to restore some movement and some of the releases are done [INAUDIBLE] as we will see.
BIJAYENDRA SINGH: Just showing the draping on the shoulder. Great blue, everything. MUSIC PLAYS/VOICES INTERSPOSED] Full color. Yeah Christmas tree. Christmas tree. Can I just stand in my window then with the lights on and tell my kids, this is the Christmas Light for this year. [MUSIC STOPS]
BIJAYENDRA SINGH: At this stage I then mark the incision. I always mark my landmarks, the acromion, the AC joint, and then draw my incision, which is along the deltoid split about a centimeter behind the interior of the acromion.
BIJAYENDRA SINGH: About ten, twelve centimeters long incision. You usually draw a line at about 7cm roughly where the auxiliary nerve is going to be from the tip of the acromion. Then start my incision. All my incisions have 1% xylocaine with adrenaline and it's injected into the plane which provides a good initial hemostasis.
BIJAYENDRA SINGH: Thick flaps are raised.
BIJAYENDRA SINGH: Now marking the acromion and about 6 to 7 centimeters again, this is just for the purpose of the video. And at this stage, I will put a stay stitch just proximal to where I think the axillary nerve is going to be, taking full thickness of the deltoid and just laying a suture and it's important to put this stitch right in the center of where the split is going to be so that you don't accidentally go further into the axilliary nerve.
BIJAYENDRA SINGH: I then release the deltoid, leaving about four or 5 millimeter of the anterior chromium and taking full thickness of the fascia. And I'll incise with the diathermine for about two-three centimeters distally then I lift off the deltoid from the chromial fascia to facilitate my acromioplasty.
BIJAYENDRA SINGH: Once I've done this bit. I will then go into the deltoid muscle, using scissors and doing dissecting and making sure I go right up to the edge of the lateral edge of the acromion. And I know it is quite safe to dissect distally. So I will go until my stay stitch because that's the safe territory making sure I do full thickness really or solve a small self retainer.
BIJAYENDRA SINGH: At this stage, especially in these traumatic cases, the bursa has become quite thick. Because of the haematoma and the bursa is normally thick anyway. You need to make sure that you take off enough bursa. This is my osteotomy to release the deltoid and doing my acromioplasty remove about four to 5 millimeters off of the chromium and this bone then I use it as a graft in the defect.
BIJAYENDRA SINGH: I make sure I've gone right up to the edge of the ACJ with my release, and then you start to release your deltoid. So this is just showing my system, the only sliver that I take off is the deltoid, which facilitates better healing as it's a bone to bone. Further dissecting the deltoid up to my split, I then feel INAUDIBLE, as I would normally do for a filus, running my finger from the posterior aspect to just feel it,
BIJAYENDRA SINGH: I do not isolate it for this procedure. I feel there is no point in doing a very minimal approach as once you take in the deltoid or from the acromion, however long you split it, the healing is still the same and by doing an adequate. I'm trying to isolate and find the greater tuberosity fragment as this is already six weeks
BIJAYENDRA SINGH: there is some fibrous healing that has happened. I feel for the movement of the fragment under the deltoid, just identifying the plane. Where to go would often release the rotated interval and make a split in the rotator cuff to achieve two things. One is to identify the fragment, and also it helps mobilize the rotator cuff.
BIJAYENDRA SINGH: So you can see here, I've managed to locate my bony fragment. So I'm going to next split the rotator cuff both round the front and the back to facilitate mobilisation and tension free repair.
BIJAYENDRA SINGH: So you can see there's still quite an extensive bursa that needs to be debrided and removed for us to be able to identify the rotator cuff easily. Now using a heavier pair of scissors quite gently mobilize the fragment from the bone base and then going anteriorly first into the rotator interval and make a split in the cuff.
BIJAYENDRA SINGH: Once I have done that, then you can start to see the humeral head underneath, I'm also going posteriorly to do, like a posterial triball slide. You can see the humeral head just sitting under the tuberosity fragment, as you can see at this stage the fragment is still not very mobile and I will need to do some more releases, although I can bring it back, it feels quite tight.
BIJAYENDRA SINGH: So at this stage what I would do is do the release further in the rotated interval. Also do a subdeltoid release preparing for the repair. Use a 5.5 millimeter swivel lock anchors. Generally put one, maybe two fiber wire with the needle into the anchor, the first anchor is going to go posterior insert, putting two sutures through there.
BIJAYENDRA SINGH: This is inserted just under the posterior edge of the, under the articular surface. Remember, the additional central holding suture can be used as well to pass through the rotator cuff.
BIJAYENDRA SINGH: My nurse is asking me, why do not I use the tap here and she had kept it open? But because the bone is soft, you can just use the anchor straight away, although they're non self punching. This is the second anchor with one suture going in the anterior part of the humeral head.
BIJAYENDRA SINGH: Once the sutures are in, then you start to pass the fiber wire suture through the anchor. I've developed this technique over a number of years, as I used to find sometimes passing the sutures through the cuff can be challenging, but a little bit of perseverance does work. It's important to remember that the strength of your repair is proportional to the number of passes through the sutures
BIJAYENDRA SINGH: through the rotator cuff. I often will incorporate the biceps long head if it is present as this reduces the chances of patient developing signs from biceps irritation and also improves the strength of the repair.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: Once I'm satisfied with the number of passes that have been undertaken I just try and see if I can reduce the one fragment to its place without putting too much pressure onto the tendon itself as otherwise, they're likely to fail. I'd like to provide a tension free repair.
BIJAYENDRA SINGH: The stay, then cleared out at the top of the humerus before I start making some drill holes for my button plate normally use a 1.6 millimeter k-wire, or you could use a drill bit of a similar size. And I use a Houston suture passer or you could use a PDS. Loop through, pull the sutures that have been put through the cuff
BIJAYENDRA SINGH: Into the, in to the humerus. Generally make about 4 to 6 holes in the upper end of humerus, depending on the spread of the sutures.
BIJAYENDRA SINGH: Make sure that the drill holes are spread around otherwise they are likely to cause crack in the upper end of the humerus.
BIJAYENDRA SINGH: Once I've made my passes, then I use this button plate which has got multiple holes. This acts as a bridge over the humerus and reduces the stress on the humerus, stopping it from cutting through the upper end of the humerus as this is generally becomes a bit softer even in the younger patients because of the immobility and the injury.
BIJAYENDRA SINGH: These holes are fairly wide spread so you can spread the sutures across. Once I've done that, I'll lay this flush to the upper end of the humerus, reduce the bony fragments. You can see on the top and
BIJAYENDRA SINGH: then start to tie the sutures. So I would hold the button with forceps and then start to tie from one end making sure that you remove all the slack in the sutures otherwise they will come loose and the tuberosity fragment is likely to migrate.
BIJAYENDRA SINGH: And see, that's a good positioning. I'll often get my assistant to do the knot tying whilst I hold the button plate in place.
BIJAYENDRA SINGH: At the end then I take another epibond suture or a fiber wire suture and do a run through stitch to close any of the gaps. I'll also do a thorough closure of the rotator interval. This does increase the risk of slight stiffness, but it provides a better and a robust repair.
BIJAYENDRA SINGH: And I'm happy to come back and deal with the stiffness at a later date if it's required but I'd rather have a strong repair to begin with.
BIJAYENDRA SINGH: These are the final pictures before closure. I always advise to take as many pictures on table as you wish and different rotation as this is the best chance To get views that the surgeons like. After this, I close the deltoid using Transocean suture with non absorbable suture material going through the deltoid, the front and the rest of the acromion.
BIJAYENDRA SINGH: If the patient is very young and has got hard bone, sometimes you may need to use a k-wire or a drill bit of 2 millimeters to starter from the cortex but most of the time the needle is strong enough to go through that, do a mattress repair at the top. And then close the rest of the deltoid using an absorbable suture as shown on my video of proximal humerus repair.
BIJAYENDRA SINGH: Use the bone removed from the acromioplasty and insert it where the gap is. If required, you can also supplement it with additional bone putty, or phone chips. The wound is closed in layers. I generally use a particular monocle for the skin. A pressure dressing is applied and the arm is placed in a sling. Get the patient doing pendulum exercises as soon as tolerable, usually after 24 hours
BIJAYENDRA SINGH: or once the block has worn off. We start active assisted at about two weeks and active movements in four weeks. Grade the physio with focusing on forward flexion and external rotation in the early phases and the abduction comes later on. I expect to get full passive movement by about three months.
BIJAYENDRA SINGH: And if the patient is still struggling, then consider a glenohumeral joint release hydrodynamic notation that stage. Thank you for watching the video. For more information or videos, please visit my YouTube channel or contact via my Secretary.
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