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Multiple Portals as Watching Portals - Smart Strategy in Chronic & Massive Rotator Cuff Tears
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Multiple Portals as Watching Portals - Smart Strategy in Chronic & Massive Rotator Cuff Tears
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T00H14M39S
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https://cadmoreoriginalmedia.blob.core.windows.net/a6561341-e581-41aa-9d48-78330c2c7dfa/Logo - Multiple Portals as Watching Portals - Smart Strategy.mp4?sv=2019-02-02&sr=c&sig=yYdshBUqlEKvA3SpI7SaBe4rtOF0PzjEx2oUpLaGPYQ%3D&st=2024-11-22T01%3A23%3A47Z&se=2024-11-22T03%3A28%3A47Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
So, my friends, how are you? This is me, Dr. Sergio Rowinski, from Shoulder Planet, here from São PaUlo, Brazil. In today's video showing you guys a very interesting idea of changing the camera and putting it in different portals, and not even, not only, in the posterior portal, and in the lateral portal, but also in the antero-supero-lateral portal,
when we have to deal with difficult, massive big tears, especially in patients with difficult body constitutions. So in this case, I am presenting to you a big tear, a massive tear, five years old, very chronic tear and the patient was very short, very obese, very hefty. It's difficult not only to position the patient, but still it's difficult sometimes to use the camera in the lateral portal and in the posterior portal.
So in this sense, in some moments of the surgery, using the camera in the antero-supero-lateral portal can be something very wise and can make this procedure much, much easier. So I hope you like the video. Don't forget to subscribe. We need your subscription, and let's see the video.
Massive tears are the most difficult kind of rotator cuff lesions to treat, due to tendon degeneration and retraction too. These cases get a little worse when these tears are so chronic, like in this case. So this case is about a 59-year-old woman who had a felt on the side walk when she was walking on the street, about five years ago, and she developed a traumatic rotator cuff lesion in her right shoulder.
Unfortunately, due to insurance plan problems, she was supposed to be operated three times in the last five years, but she was not. She came to me about six months ago, so I asked for a new MRI. This is a recent MRI, a coronal view, in T2, revealing a massive and retracted lesion of the postero-superior cuff. And here in this other image, we can see another coronal view, still in T2, in which we can see that she had a very retracted esion of the supra and probably the infra spinatus, too.
She was operated in November 9 2011, and so this is her arthroscopy. So this is the right shoulder. You will see the biceps and we established an anterior portal and then we immediately tested the biceps. We just put it out of the biceps pulley, and the biceps was quite ugly. We found lots of synovitis and fraying, and definitely that biceps would have to be tenotomised and if possible, even tenodesed.
So we performed a very simple and fast tenotomy, and then we performed a very simple debridement of the biceps anchor. And we then immediately moved to the subacromial space. So then we had to remove all the bursitis and all the synovitis, and now we are cleaning the antero lateral gutter. As I always say, this is a very important part of the surgery, and now we are cleaning the anterior gutter and now we can see that she has a very big lesion. Here
we can see the biceps, and a very big lesion of the posterior superior cuff. So then we are continuing cleaning the lateral gutter. This is a very important part of the surgery. And after that, we immediately moved the camera to the lateral portal. So this is her lesion, a very important lesion. And then we established immediately an antero supero lateral portal, with a spinal needle, and then we immediately accessed it the tendon mobility.
So the tendon was not, not very mobile. Here we are seeing the mobility of the posterior part of the tendon. So we would have, for sure, to perform some releases and, then, using a soft tissue shaver and electro cautery we performed some releases in the distal part of the clavicle and in the posterior part of the subacromial space, as we are seeing now. Then we entered through the antero supero lateral portal with a very small osteome, and we debrided
the adherences between the superior part of the glenoid and the postero-superior cuff, as an assistant very gently holded the cuff. Now we are reaccessing mobility. The tendon was reasonably mobile, so we continued doing a lot of releases still working through the antero-supero-lateral portal. And, in that moment, we first started to see where we would put the first anchor.
So before putting the first anchor, we would have to perform a very good debridement of the greater tuberosity, in order to create a bony bed, a bleeding base, in which the tendon would be put and compressed to. So then we established, with a spinal needle, a good position for the first anchor. And then we put that first anchor in a very standard fashion, using first a probe. And then we made the format of the anchor and then we would have to put 5.0 mm, I mean, a 6.0 mm double-loaded absorbable anchor.
So then the anchor was placed. It was really in a good position. So we first entered with a bird beak through the posterior portal and, in a retrograde fashion, we would put the first white suture out of the shoulder through the posterior portal. And then, before tying that knot, we entered through the lateral portal, with an expressew device, and passed
The second suture in the very posterior part of the cuff. And then we would have to put that suture out of the shoulder, with a suture grasper, through the anterior portal. We can see that the camera, now, is in the antero superolateral portal and, through the lateral portal. we tie the first knot, a sliding DUNKAN not, and we have to put a lot of compression in order for the tendon to heal in the bony bed that we had just created.
Then we cut that knot and put the two blue sutures out of the lateral portal and tie the second knot, a sliding Dunkan knot again, putting a lot of pressure in the tendon. And then, once the knot was done, it would just have to be cut. At that moment, we would have to put a second anchor, we established that position using a spinal needle, we can see that the camera is in the antero supero lateral portal.
And then we did the same thing again. We passed a probe, and then, when the hole was done, we would have just to make the right space for the anchor, and then we would have to put the second anchor again. A double-loaded anchor. At that moment, we changed the portals, so now the camera is in the posterior portal, and then we would have to isolate the sutures,
so we put the white one in the lateral portal, and, then, using an expressew device, we passed the first suture from the second anchor, in the junction between the Supra and the infraspinatu, and we would have to put that suture out of the shoulder through the antero supero lateral portal, and then we would have to put both parts of the suture in the lateral portal, to tie
the first suture from the second anchor. So now we are doing another suture. And a sliding Dunkan knot again. And once the knot was tied, it would just have to be cut, but we always have to put some pressure in order for the tendon to heal in the bony bed that we had just created. And then the knot was cut.
Here we see that the knot is being cut and then we would have to do the same thing. So we put again the blue sutures in the lateral portal an using an expressew device we passed that blue suture in a more anterior part of the supraspinatus. Then, again, with a suture Grasper through the antero supero lateral portal, we pulled that suture out of the shoulder.
So once that suture was out of the shoulder, we would have to do the same thing again, put both parts of the blue suture in the lateral cannula and tie the second knot from the second anchor. Now we are putting some pressure again. And once the knot was done, it would have to be cut. And then using a spinal needle, we established a good position for the third anchor, that would be very anterior, in the very anterior part of the greater tuberosity.
So then we did the same steps. We used a puncture, and, very hopefully, that lady had a good bone quality and then the anchor would have to be put in the same manner. We used a third anchor, again, a 6.0 absorbable double loaded anchor, And once the anchor was in place we would have to isolate the sutures not to make a mess with them, so we put the blue one in the antero-supero-lateral portal, and the white one in the lateral portal.
It's very important to isolate sutures, not to make a mess with them inside of the subacromial space. And then we passed the blue one, in a very anterior part of the greater, of the supraspinatus, I mean, and then, as we were in a very anterior part of the subacromial space, we put that suture out of the shoulder through the anterior portal. So now we are putting the blue one out of the anterior portal.
And then we isolated them in the antero-supero-lateral portal. And then, before tying the knot, we passed, through for the lateral portal, the white one, again, in a very anterior part of the supraspinatus, So we put that suture out of the anterior portal and, again, isolated both parts of the white suture in the lateral portal, and then we would have to tie both knots. So we tied, first,
the white one, again in the same manner, some compression and then the knot would have to be cut. And then we tie the blue suture of the third anchor. We tied that knot through the antero supero lateral portal, we can see that we always put a lot of pressure, because we want the tendon to heal in the bony bed, and then before cutting that knot, we would do a subacromial soft tissue tenodesis.
So we passed a spinal needle through biceps, with a PROLENe suture, and we put that prolene suture out of the shoulder through the antero supero lateral cannula. And then we passed the blue suture through the biceps and made a soft tissue tenodesis. So this is the final image. The final result, we can see that we could re-establish a very reasonable footprint as we externally and internally rotate the shoulder.
We can see that here in the lateral view, we can see the infraspinatus, and then the supraspinatus, and, in the very anterior part of the subacromial space, the soft tissue tenodesis. And at that moment, the surgery was finished. So, my friends, I hope you really enjoyed it. A big tear. And the idea of using the camera in different portals, in different moments of the surgery is a very good one.
And especially keep in mind using the camera in the antero supero lateral portal It's something that can be used, and can be very interesting, when we are dealing with difficult tears. So don't forget again to subscribe. Give us your like. Leave your comment. See you in the next video. And as Dr. Sergio always says and loves to say, never stop flying.
Segment:0 .
So, my friends, how are you? This is me, Dr. Sergio Rowinski, from Shoulder Planet, here from São PaUlo, Brazil. In today's video showing you guys a very interesting idea of changing the camera and putting it in different portals, and not even, not only, in the posterior portal, and in the lateral portal, but also in the antero-supero-lateral portal,
when we have to deal with difficult, massive big tears, especially in patients with difficult body constitutions. So in this case, I am presenting to you a big tear, a massive tear, five years old, very chronic tear and the patient was very short, very obese, very hefty. It's difficult not only to position the patient, but still it's difficult sometimes to use the camera in the lateral portal and in the posterior portal.
So in this sense, in some moments of the surgery, using the camera in the antero-supero-lateral portal can be something very wise and can make this procedure much, much easier. So I hope you like the video. Don't forget to subscribe. We need your subscription, and let's see the video.
Massive tears are the most difficult kind of rotator cuff lesions to treat, due to tendon degeneration and retraction too. These cases get a little worse when these tears are so chronic, like in this case. So this case is about a 59-year-old woman who had a felt on the side walk when she was walking on the street, about five years ago, and she developed a traumatic rotator cuff lesion in her right shoulder.
Unfortunately, due to insurance plan problems, she was supposed to be operated three times in the last five years, but she was not. She came to me about six months ago, so I asked for a new MRI. This is a recent MRI, a coronal view, in T2, revealing a massive and retracted lesion of the postero-superior cuff. And here in this other image, we can see another coronal view, still in T2, in which we can see that she had a very retracted esion of the supra and probably the infra spinatus, too.
She was operated in November 9 2011, and so this is her arthroscopy. So this is the right shoulder. You will see the biceps and we established an anterior portal and then we immediately tested the biceps. We just put it out of the biceps pulley, and the biceps was quite ugly. We found lots of synovitis and fraying, and definitely that biceps would have to be tenotomised and if possible, even tenodesed.
So we performed a very simple and fast tenotomy, and then we performed a very simple debridement of the biceps anchor. And we then immediately moved to the subacromial space. So then we had to remove all the bursitis and all the synovitis, and now we are cleaning the antero lateral gutter. As I always say, this is a very important part of the surgery, and now we are cleaning the anterior gutter and now we can see that she has a very big lesion. Here
we can see the biceps, and a very big lesion of the posterior superior cuff. So then we are continuing cleaning the lateral gutter. This is a very important part of the surgery. And after that, we immediately moved the camera to the lateral portal. So this is her lesion, a very important lesion. And then we established immediately an antero supero lateral portal, with a spinal needle, and then we immediately accessed it the tendon mobility.
So the tendon was not, not very mobile. Here we are seeing the mobility of the posterior part of the tendon. So we would have, for sure, to perform some releases and, then, using a soft tissue shaver and electro cautery we performed some releases in the distal part of the clavicle and in the posterior part of the subacromial space, as we are seeing now. Then we entered through the antero supero lateral portal with a very small osteome, and we debrided
the adherences between the superior part of the glenoid and the postero-superior cuff, as an assistant very gently holded the cuff. Now we are reaccessing mobility. The tendon was reasonably mobile, so we continued doing a lot of releases still working through the antero-supero-lateral portal. And, in that moment, we first started to see where we would put the first anchor.
So before putting the first anchor, we would have to perform a very good debridement of the greater tuberosity, in order to create a bony bed, a bleeding base, in which the tendon would be put and compressed to. So then we established, with a spinal needle, a good position for the first anchor. And then we put that first anchor in a very standard fashion, using first a probe. And then we made the format of the anchor and then we would have to put 5.0 mm, I mean, a 6.0 mm double-loaded absorbable anchor.
So then the anchor was placed. It was really in a good position. So we first entered with a bird beak through the posterior portal and, in a retrograde fashion, we would put the first white suture out of the shoulder through the posterior portal. And then, before tying that knot, we entered through the lateral portal, with an expressew device, and passed
The second suture in the very posterior part of the cuff. And then we would have to put that suture out of the shoulder, with a suture grasper, through the anterior portal. We can see that the camera, now, is in the antero superolateral portal and, through the lateral portal. we tie the first knot, a sliding DUNKAN not, and we have to put a lot of compression in order for the tendon to heal in the bony bed that we had just created.
Then we cut that knot and put the two blue sutures out of the lateral portal and tie the second knot, a sliding Dunkan knot again, putting a lot of pressure in the tendon. And then, once the knot was done, it would just have to be cut. At that moment, we would have to put a second anchor, we established that position using a spinal needle, we can see that the camera is in the antero supero lateral portal.
And then we did the same thing again. We passed a probe, and then, when the hole was done, we would have just to make the right space for the anchor, and then we would have to put the second anchor again. A double-loaded anchor. At that moment, we changed the portals, so now the camera is in the posterior portal, and then we would have to isolate the sutures,
so we put the white one in the lateral portal, and, then, using an expressew device, we passed the first suture from the second anchor, in the junction between the Supra and the infraspinatu, and we would have to put that suture out of the shoulder through the antero supero lateral portal, and then we would have to put both parts of the suture in the lateral portal, to tie
the first suture from the second anchor. So now we are doing another suture. And a sliding Dunkan knot again. And once the knot was tied, it would just have to be cut, but we always have to put some pressure in order for the tendon to heal in the bony bed that we had just created. And then the knot was cut.
Here we see that the knot is being cut and then we would have to do the same thing. So we put again the blue sutures in the lateral portal an using an expressew device we passed that blue suture in a more anterior part of the supraspinatus. Then, again, with a suture Grasper through the antero supero lateral portal, we pulled that suture out of the shoulder.
So once that suture was out of the shoulder, we would have to do the same thing again, put both parts of the blue suture in the lateral cannula and tie the second knot from the second anchor. Now we are putting some pressure again. And once the knot was done, it would have to be cut. And then using a spinal needle, we established a good position for the third anchor, that would be very anterior, in the very anterior part of the greater tuberosity.
So then we did the same steps. We used a puncture, and, very hopefully, that lady had a good bone quality and then the anchor would have to be put in the same manner. We used a third anchor, again, a 6.0 absorbable double loaded anchor, And once the anchor was in place we would have to isolate the sutures not to make a mess with them, so we put the blue one in the antero-supero-lateral portal, and the white one in the lateral portal.
It's very important to isolate sutures, not to make a mess with them inside of the subacromial space. And then we passed the blue one, in a very anterior part of the greater, of the supraspinatus, I mean, and then, as we were in a very anterior part of the subacromial space, we put that suture out of the shoulder through the anterior portal. So now we are putting the blue one out of the anterior portal.
And then we isolated them in the antero-supero-lateral portal. And then, before tying the knot, we passed, through for the lateral portal, the white one, again, in a very anterior part of the supraspinatus, So we put that suture out of the anterior portal and, again, isolated both parts of the white suture in the lateral portal, and then we would have to tie both knots. So we tied, first,
the white one, again in the same manner, some compression and then the knot would have to be cut. And then we tie the blue suture of the third anchor. We tied that knot through the antero supero lateral portal, we can see that we always put a lot of pressure, because we want the tendon to heal in the bony bed, and then before cutting that knot, we would do a subacromial soft tissue tenodesis.
So we passed a spinal needle through biceps, with a PROLENe suture, and we put that prolene suture out of the shoulder through the antero supero lateral cannula. And then we passed the blue suture through the biceps and made a soft tissue tenodesis. So this is the final image. The final result, we can see that we could re-establish a very reasonable footprint as we externally and internally rotate the shoulder.
We can see that here in the lateral view, we can see the infraspinatus, and then the supraspinatus, and, in the very anterior part of the subacromial space, the soft tissue tenodesis. And at that moment, the surgery was finished. So, my friends, I hope you really enjoyed it. A big tear. And the idea of using the camera in different portals, in different moments of the surgery is a very good one.
And especially keep in mind using the camera in the antero supero lateral portal It's something that can be used, and can be very interesting, when we are dealing with difficult tears. So don't forget again to subscribe. Give us your like. Leave your comment. See you in the next video. And as Dr. Sergio always says and loves to say, never stop flying.
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