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Name:
Arthroscopic Superior Capsular Reconstruction For An Irreparable Rotator Cuff Tear
Description:
Arthroscopic Superior Capsular Reconstruction For An Irreparable Rotator Cuff Tear
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T00H18M03S
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https://cadmoreoriginalmedia.blob.core.windows.net/8ce50115-255b-41fd-b4e1-7b6598289694/Arthroscopic superior capsular reconstruction for an irrepar.mp4?sv=2019-02-02&sr=c&sig=oHeC8c9m75slhLRHXiMzKKlsBKd3TdGRRm2ZSfLSJbU%3D&st=2024-11-21T13%3A14%3A30Z&se=2024-11-21T15%3A19%3A30Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ALEJANDRO BADIA: Today, we'll be discussing arthroscopic superior capsular reconstruction in an irreparable rotator cuff tear that actually had previous surgeries that have failed. Here is a positioning in a patient, a left lateral decubitus with traction on the arm at 60 degrees. Posteriorly, we will insufflate the joint with lactating ringers, allowing us to find the glenohumeral joint and then make the posterior portal
ALEJANDRO BADIA: and entering with a standard four millimeter shoulder arthroscope. Looking from the posterior portal, we immediately see a great deal of sinovitis and the previous sutures from the failed repairs. We will now debride aggressively so that we can identify the superior glenoid. Direct lateral portal is made here and we will begin to debride the greater tuberosity in preparation for the attachment of the most lateral aspect of the dermal allograft, which we'll use to reconstruct the superior capsule.
ALEJANDRO BADIA: You will see multiple sutures being removed as we wanted to delineate the area of good subchondral bone where we will be inserting the anchors, essentially avoiding the locations of previous anchors for the failed cuff repair. It should be noted that the SCR is an indicated procedure when the patient does not have arthritic changes yet has an irreparable rotator cuff lesion.
ALEJANDRO BADIA: We see there the anchor being removed and we will have to place the anchors more laterally. And this patient was too young and active to go immediately to a reverse shoulder replacement. It is essentially a salvage procedure. We are now preparing for the anchor placement. Here we place the guidewire where we will over drill and that will be for the placement of the 3.9 millimeter bio composite, not less corkscrews that will go in the superior glenoid rim or more so the neck in preparation for the attachment of the most medial aspect of the dermal graft.
ALEJANDRO BADIA: Now we are preparing for the more posterior glenoid corkscrew anchor. We are ensuring that the anchors are placed far enough from each other, but in good quality bone at the superior glenoid. This is why there is importance to debride the superior glenoid so that you can visualize where the anchors are being placed.
ALEJANDRO BADIA: So essentially there is a guidewire inside a cannula. We're now drilling the hole for the more posterior glenoid anchor, and at this point, the anchor is being inserted. This will include shuttling stitch that will be used to shuttle suture through the dermal graft in the most medial port.
ALEJANDRO BADIA: Now we will be inserting the swivel lock anchors, which will go into the juncture of the articular surface and the greater tuberosity, this is essentially the medial row of the two rows that will be going on the greater tuberosity. In this particular patient, it was challenging because of the previous anchors, and we had to ensure that we had a good real estate here in order to gain purchase of the anchor.
ALEJANDRO BADIA: This is the top that's inserted up to the wider portion. So now we will locate that previously drilled hole and again being careful to avoid the cavity, which is more lateral from a previous anchor and prior surgery. This is done through a more superior lateral portal, and as we turn the swivel lock anchor, we can determine at that point if there is sufficient purchase in bone.
ALEJANDRO BADIA: That anchor sufficed. In this one, we went a bit more posterior than we usually would for that same reason in order to ensure there is good quality bone. We see fat droplets emanating here and we can tell that this should have a good purchase for the second swivel lock anchor.
ALEJANDRO BADIA: This is a 4.75 anchor using fiber tapes. That type of suture will have more strength so that it doesn't pull, pull through the tissue. It's important to ensure that you are tapping down the anchor in the same trajectory as your initial tap. Once we screw those anchors in, we'll have to deliver the sutures externally
ALEJANDRO BADIA: and at this point we add the special lateral rubber cannula, which will be using throughout the procedure. In order to assist with suture management, we use this inserter that essentially separates the region into four quadrants so that we ensure that the posterior sutures go in that direction. At this point, we're now retrieving the shuttling stitch from the knotless corkscrew anchor that's in the superior glenoid, and the first one will be brought through the more anterior medial quadrant.
ALEJANDRO BADIA: Now we're going for the second shuttling stitch. Again, it's important to keep the sutures well organized, as the latter part of procedure will depend completely upon this. Now we're bringing the fiber wire tape sutures out the more lateral quadrant.
ALEJANDRO BADIA: This one's posterior. So that device, as you see there, separates into four quadrants. We now will take the dermal allograft, which is a special graft in particular for this surgery. This is actually taken from the lumbar area in a human donor. and we can either measure the graft intra articulately, but because of the size of the patient and prior experience, we have a set dimension that we will mark out on a graft and now cut it.
ALEJANDRO BADIA: This is cut on a back table on top of multiple towels because the graft is quite thick. We will now on the lateral side make entry holes which later will pass the suture through. This is for the tuberosity side. We are now grabbing the sutures from the glenoid anchors.
ALEJANDRO BADIA: This is the shuttling suture that will be then passed through the most medial aspect of the dermal graft and we do this in a manner so that it will be essentially a mattress stitch so it needs to be passed in two different directions. So that is for the anterior glenoid and we will now be retrieving that, that shuttle stitch so that we can pull it through the graft.
ALEJANDRO BADIA: As mentioned, suture management here is critical, so we are loading the loop on the shuttling stitch, which we will now be pulling as you're seeing from the most medial portal there as we pull. And at this point, there's always a bit of resistance because the suture is being passed through
ALEJANDRO BADIA: and there we grab the loop, which will diminish the resistance, and it's important to maintain the right tension. The same will be done now for the more posterior of the two anchors in the glenoid and the same process will be repeated. We will use that suture passer again in two different directions
ALEJANDRO BADIA: so in order to create essentially a horizontal mattress stitch. So we will go now through the more medial posterior quadrant and again, grab the shuttling stitch. The suture from the dermal allograft is in place through the loop and now we will pull that through
ALEJANDRO BADIA: and this will essentially secure the medial aspect of the construct so that once we insert the allograft for the superior capsular reconstruction, we will be pulling on those sutures and anchoring them down. The sutures from the medial row on the tuberosity are now passed through the holes that we previously made,
ALEJANDRO BADIA: again, ensuring that we have the correct quadrant so that we are maintaining the sutures in the appropriate orientation. You can see clearly here that the sutures are well organized, and that really requires working as a team in the operating room to achieve that. Once we've done that, we can now remove the device that goes within the cannula that was separating the entryway into the four quadrants
ALEJANDRO BADIA: and now we will grab the dermal allograft. This is done with a heavy needle holder and we will fold it, I say like a New York hot dog and pass it manually through that portal, pulling on the sutures to maintain tension. So you see there, that's the most medial aspect of that allograft
ALEJANDRO BADIA: and we are taking up the slack with the sutures and then bringing it down to the superior glenoid rim. As we pull on these sutures, they will tighten so there's no need to tie knots here, which will be challenging in this particular scenario. Now we can also use a knot pusher to ensure that the graft is sitting on the superior glenoid and we've taken out the slack.
ALEJANDRO BADIA: We now move to creating the hole for the punch, which will be for the lateral row of the anchors in the tuberosity. Again, this was more challenging in this particular patient due to the previous anchors. So these sutures will be crossed from the medial row and you can see there's two different color sutures because they are being crossed, which will give additional strength to the fixation of that graft.
ALEJANDRO BADIA: So we will soon see the lateral graft being brought down to the tuberosity, and again, we are quite lateral here, you can see fat droplets and the graft is inserted with good tension. Spin back the inserter and ensure there's a good purchase before we cut the sutures.
ALEJANDRO BADIA: Now we will retrieve the suture from a more posterior portion of the tuberosity and loaded onto the anchor. This will be the more posterior anchor. Again, quite lateral on the tuberosity due to the bone quality and previous surgery. Once a tap is removed, we localize that hole and then as we're bringing it down, we will now pull tightly on the sutures
ALEJANDRO BADIA: and insert the anchor. This will essentially serve as a check rein for superior migration of the humeral head, which is what we are trying to avoid to give a lever arm for the deltoid to function and also to prevent superior humeral head migration and development of post traumatic arthropathy.
ALEJANDRO BADIA: We are now cutting the sutures from the superior glenoid rim and you can see that the graft is quite tight. In order to give that improved coverage, we can now take the remnant to the cuff. In this case, a small portion of the infraspinatus was remaining and we are passing suture tape through the posterior margin of the dermal allograft
ALEJANDRO BADIA: and now grabbing a portion of the remaining portion of the infraspinatus. We are using a Duncan loop here, a type of arthroscopic stitch and passing it through the loop and this will be a sliding knot. We use a knot pusher here and we'll push that knot down, basically bringing the dermal allograft towards the infraspinatus posteriorly and helping to close that gap.
ALEJANDRO BADIA: We should get ingrowth to the margins of this graft so this particular step is important and we'll now lock that. This will further strengthen the construct and provide for essentially complete coverage of the interval between the glenoid there, and you can see it's quite taut and the great tuberosity there.
ALEJANDRO BADIA: So this will again prevent superior migration of the humeral head. And you can see there this is tight like a drum. That is what we want to achieve. We will then close the portals. This is the posterior portal. Those were superior micro portals used to simply insert the medial row of the swivel lock anchors.
ALEJANDRO BADIA: The lateral portal is a bit larger because of the working cannula to pass the graft. This is absorbable sutures that we tend to use in our arthroscopy and is really no need to remove sutures. Patients appreciate that and it's a good time saver. This is a 3-0 vicryl type suture.
ALEJANDRO BADIA: We also will now inject a mix connective tissue allograft that will be done at the juncture between the dermal allograft and greater tuberosity, followed by platelet rich plasma, which we took from the patient's blood when his IV was inserted in the holding area. Sterile dressings are placed over 0 form. Bulky dressing will be applied and the patient will be placed into a sling.
ALEJANDRO BADIA: We tend to use a sling with an abduction pillow for patient comfort and also to minimize the tension on the SCR graft. It's important that this patient be protected without motion, either passive or certainly active for approximately a five to even six week period in order to allow for that graft to heal properly and again, avoid migration of the head. At that point we will begin therapy.
ALEJANDRO BADIA: This is all done in order to try to create a biologic healing environment to allow for healing of this dermal allograft. This is an excellent alternative to trying to reconstruct a rotator cuff, which is essentially not present and perhaps will stave off the need for reverse shoulder arthroplasty in the future. Thank you for your attention. [VIDEO ENDS]
Segment:0 .
ALEJANDRO BADIA: Today, we'll be discussing arthroscopic superior capsular reconstruction in an irreparable rotator cuff tear that actually had previous surgeries that have failed. Here is a positioning in a patient, a left lateral decubitus with traction on the arm at 60 degrees. Posteriorly, we will insufflate the joint with lactating ringers, allowing us to find the glenohumeral joint and then make the posterior portal
ALEJANDRO BADIA: and entering with a standard four millimeter shoulder arthroscope. Looking from the posterior portal, we immediately see a great deal of sinovitis and the previous sutures from the failed repairs. We will now debride aggressively so that we can identify the superior glenoid. Direct lateral portal is made here and we will begin to debride the greater tuberosity in preparation for the attachment of the most lateral aspect of the dermal allograft, which we'll use to reconstruct the superior capsule.
ALEJANDRO BADIA: You will see multiple sutures being removed as we wanted to delineate the area of good subchondral bone where we will be inserting the anchors, essentially avoiding the locations of previous anchors for the failed cuff repair. It should be noted that the SCR is an indicated procedure when the patient does not have arthritic changes yet has an irreparable rotator cuff lesion.
ALEJANDRO BADIA: We see there the anchor being removed and we will have to place the anchors more laterally. And this patient was too young and active to go immediately to a reverse shoulder replacement. It is essentially a salvage procedure. We are now preparing for the anchor placement. Here we place the guidewire where we will over drill and that will be for the placement of the 3.9 millimeter bio composite, not less corkscrews that will go in the superior glenoid rim or more so the neck in preparation for the attachment of the most medial aspect of the dermal graft.
ALEJANDRO BADIA: Now we are preparing for the more posterior glenoid corkscrew anchor. We are ensuring that the anchors are placed far enough from each other, but in good quality bone at the superior glenoid. This is why there is importance to debride the superior glenoid so that you can visualize where the anchors are being placed.
ALEJANDRO BADIA: So essentially there is a guidewire inside a cannula. We're now drilling the hole for the more posterior glenoid anchor, and at this point, the anchor is being inserted. This will include shuttling stitch that will be used to shuttle suture through the dermal graft in the most medial port.
ALEJANDRO BADIA: Now we will be inserting the swivel lock anchors, which will go into the juncture of the articular surface and the greater tuberosity, this is essentially the medial row of the two rows that will be going on the greater tuberosity. In this particular patient, it was challenging because of the previous anchors, and we had to ensure that we had a good real estate here in order to gain purchase of the anchor.
ALEJANDRO BADIA: This is the top that's inserted up to the wider portion. So now we will locate that previously drilled hole and again being careful to avoid the cavity, which is more lateral from a previous anchor and prior surgery. This is done through a more superior lateral portal, and as we turn the swivel lock anchor, we can determine at that point if there is sufficient purchase in bone.
ALEJANDRO BADIA: That anchor sufficed. In this one, we went a bit more posterior than we usually would for that same reason in order to ensure there is good quality bone. We see fat droplets emanating here and we can tell that this should have a good purchase for the second swivel lock anchor.
ALEJANDRO BADIA: This is a 4.75 anchor using fiber tapes. That type of suture will have more strength so that it doesn't pull, pull through the tissue. It's important to ensure that you are tapping down the anchor in the same trajectory as your initial tap. Once we screw those anchors in, we'll have to deliver the sutures externally
ALEJANDRO BADIA: and at this point we add the special lateral rubber cannula, which will be using throughout the procedure. In order to assist with suture management, we use this inserter that essentially separates the region into four quadrants so that we ensure that the posterior sutures go in that direction. At this point, we're now retrieving the shuttling stitch from the knotless corkscrew anchor that's in the superior glenoid, and the first one will be brought through the more anterior medial quadrant.
ALEJANDRO BADIA: Now we're going for the second shuttling stitch. Again, it's important to keep the sutures well organized, as the latter part of procedure will depend completely upon this. Now we're bringing the fiber wire tape sutures out the more lateral quadrant.
ALEJANDRO BADIA: This one's posterior. So that device, as you see there, separates into four quadrants. We now will take the dermal allograft, which is a special graft in particular for this surgery. This is actually taken from the lumbar area in a human donor. and we can either measure the graft intra articulately, but because of the size of the patient and prior experience, we have a set dimension that we will mark out on a graft and now cut it.
ALEJANDRO BADIA: This is cut on a back table on top of multiple towels because the graft is quite thick. We will now on the lateral side make entry holes which later will pass the suture through. This is for the tuberosity side. We are now grabbing the sutures from the glenoid anchors.
ALEJANDRO BADIA: This is the shuttling suture that will be then passed through the most medial aspect of the dermal graft and we do this in a manner so that it will be essentially a mattress stitch so it needs to be passed in two different directions. So that is for the anterior glenoid and we will now be retrieving that, that shuttle stitch so that we can pull it through the graft.
ALEJANDRO BADIA: As mentioned, suture management here is critical, so we are loading the loop on the shuttling stitch, which we will now be pulling as you're seeing from the most medial portal there as we pull. And at this point, there's always a bit of resistance because the suture is being passed through
ALEJANDRO BADIA: and there we grab the loop, which will diminish the resistance, and it's important to maintain the right tension. The same will be done now for the more posterior of the two anchors in the glenoid and the same process will be repeated. We will use that suture passer again in two different directions
ALEJANDRO BADIA: so in order to create essentially a horizontal mattress stitch. So we will go now through the more medial posterior quadrant and again, grab the shuttling stitch. The suture from the dermal allograft is in place through the loop and now we will pull that through
ALEJANDRO BADIA: and this will essentially secure the medial aspect of the construct so that once we insert the allograft for the superior capsular reconstruction, we will be pulling on those sutures and anchoring them down. The sutures from the medial row on the tuberosity are now passed through the holes that we previously made,
ALEJANDRO BADIA: again, ensuring that we have the correct quadrant so that we are maintaining the sutures in the appropriate orientation. You can see clearly here that the sutures are well organized, and that really requires working as a team in the operating room to achieve that. Once we've done that, we can now remove the device that goes within the cannula that was separating the entryway into the four quadrants
ALEJANDRO BADIA: and now we will grab the dermal allograft. This is done with a heavy needle holder and we will fold it, I say like a New York hot dog and pass it manually through that portal, pulling on the sutures to maintain tension. So you see there, that's the most medial aspect of that allograft
ALEJANDRO BADIA: and we are taking up the slack with the sutures and then bringing it down to the superior glenoid rim. As we pull on these sutures, they will tighten so there's no need to tie knots here, which will be challenging in this particular scenario. Now we can also use a knot pusher to ensure that the graft is sitting on the superior glenoid and we've taken out the slack.
ALEJANDRO BADIA: We now move to creating the hole for the punch, which will be for the lateral row of the anchors in the tuberosity. Again, this was more challenging in this particular patient due to the previous anchors. So these sutures will be crossed from the medial row and you can see there's two different color sutures because they are being crossed, which will give additional strength to the fixation of that graft.
ALEJANDRO BADIA: So we will soon see the lateral graft being brought down to the tuberosity, and again, we are quite lateral here, you can see fat droplets and the graft is inserted with good tension. Spin back the inserter and ensure there's a good purchase before we cut the sutures.
ALEJANDRO BADIA: Now we will retrieve the suture from a more posterior portion of the tuberosity and loaded onto the anchor. This will be the more posterior anchor. Again, quite lateral on the tuberosity due to the bone quality and previous surgery. Once a tap is removed, we localize that hole and then as we're bringing it down, we will now pull tightly on the sutures
ALEJANDRO BADIA: and insert the anchor. This will essentially serve as a check rein for superior migration of the humeral head, which is what we are trying to avoid to give a lever arm for the deltoid to function and also to prevent superior humeral head migration and development of post traumatic arthropathy.
ALEJANDRO BADIA: We are now cutting the sutures from the superior glenoid rim and you can see that the graft is quite tight. In order to give that improved coverage, we can now take the remnant to the cuff. In this case, a small portion of the infraspinatus was remaining and we are passing suture tape through the posterior margin of the dermal allograft
ALEJANDRO BADIA: and now grabbing a portion of the remaining portion of the infraspinatus. We are using a Duncan loop here, a type of arthroscopic stitch and passing it through the loop and this will be a sliding knot. We use a knot pusher here and we'll push that knot down, basically bringing the dermal allograft towards the infraspinatus posteriorly and helping to close that gap.
ALEJANDRO BADIA: We should get ingrowth to the margins of this graft so this particular step is important and we'll now lock that. This will further strengthen the construct and provide for essentially complete coverage of the interval between the glenoid there, and you can see it's quite taut and the great tuberosity there.
ALEJANDRO BADIA: So this will again prevent superior migration of the humeral head. And you can see there this is tight like a drum. That is what we want to achieve. We will then close the portals. This is the posterior portal. Those were superior micro portals used to simply insert the medial row of the swivel lock anchors.
ALEJANDRO BADIA: The lateral portal is a bit larger because of the working cannula to pass the graft. This is absorbable sutures that we tend to use in our arthroscopy and is really no need to remove sutures. Patients appreciate that and it's a good time saver. This is a 3-0 vicryl type suture.
ALEJANDRO BADIA: We also will now inject a mix connective tissue allograft that will be done at the juncture between the dermal allograft and greater tuberosity, followed by platelet rich plasma, which we took from the patient's blood when his IV was inserted in the holding area. Sterile dressings are placed over 0 form. Bulky dressing will be applied and the patient will be placed into a sling.
ALEJANDRO BADIA: We tend to use a sling with an abduction pillow for patient comfort and also to minimize the tension on the SCR graft. It's important that this patient be protected without motion, either passive or certainly active for approximately a five to even six week period in order to allow for that graft to heal properly and again, avoid migration of the head. At that point we will begin therapy.
ALEJANDRO BADIA: This is all done in order to try to create a biologic healing environment to allow for healing of this dermal allograft. This is an excellent alternative to trying to reconstruct a rotator cuff, which is essentially not present and perhaps will stave off the need for reverse shoulder arthroplasty in the future. Thank you for your attention. [VIDEO ENDS]
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