Rotator cuff and long head of the biceps brachii (LHB) pathology are frequently concomitant. Successful surgical treatment requires appropriately addressing both issues. While many techniques exist, the authors have found the use of a suture-bridging repair of the rotator cuff tendon in conjunction with an arthroscopically assisted open subpectoral LHB tenodesis to provide a minimally invasive technique that is straightforward to perform and results in excellent patient outcomes. Step-by-step instructions for both procedures, including patient positioning, incision sites, and intraoperative techniques, will be displayed using videography. Tips, pitfalls, and postoperative considerations will also be reviewed.
Keywords: rotator cuff repair, shoulder arthroscopy positioning, subpectoral biceps tenodesis
? Dependent upon preoperative surgical planning, including patient factors and surgeon preference. The patient presented here has a full thickness tear of the supraspinatus tendon (SST), loose bodies within the synovium of the long head of the biceps brachii tendon (LHBT), and painful acromioclavicular joint (ACJ) degeneration and osteolysis (? Fig. 10.1, ? Fig. 10.2).
? Standard beach chair1 (? Fig. 10.3):
? Patient is sat fully upright to aid in visualization, not a semi-upright position.
Fig. 10.1 Radiographs of the patient?s right shoulder. (a) Anteroposterior, and (b) axillary views demonstrating multiple, large loose bodies.
Fig. 10.2 Magnetic resonance imaging of the patient?s right shoulder. (a) Coronal oblique, and (b) sagittal far lateral images demonstrate a full thickness tear of the supraspinatus tendon (SST) with multiple large loose bodies in the subacromial space and biceps synovium. (c) Sagittal medial image demonstrates impingement of the anterior acromion on the SST with deformation of the tendon.
Fig. 10.3 Patient positioning (a) prior to preparation, and (b) after draping. Beach chair position with bed slightly flexed. Arthroscopy tower and equipment are positioned at the foot of the bed. Note position of arm holder (SPIDER2, Smith & Nephew, Andover, MA) with the proximal portion of the mechanical arm positioned such that it will unobtrusively fit under the bed, out of the way, during the case (red asterisk). A horizontal bar placed between two IV poles will allow the patient to be draped and still have easy anesthesia access. One arthroscope monitor can be positioned just above this bar (red arrow). To ease preparation, the arm can be hung with a kerlix loop and IV pole (yellow asterisk). The hand is prepped at the surgeon?s discretion. It need not be prepped if carefully covered with an impervious stockinet, taking care not to contaminate the shoulder/arm.
? Head and neck carefully placed in a neutral and well-padded position.
? Nonoperative arm support. Arm relaxed at side. Shoulder slightly forward flexed. Elbow less than 90.
? Lower back in contact with the chair. An extra table pad placed under the patient?s thighs will help prevent the patient from slipping down the bed as well as contribute to hip/knee flexion. Additional table flexion is also helpful.
? Bilateral lower leg sequential compression devices on and functioning.
? An operative arm holder is useful and unobtrusive. Attach the arm holder to the side bed rail on the section with the patient?s feet. Angle the body of the holder with the mechanical arm 45 toward the floor from the bed (? Fig. 10.3a).
? On anesthesia?s side of the bed, a horizontal bar between two IV poles allows the drapes to be out of the operative field, maintain sterility, and give anesthesia easy access to the patient (? Fig. 10.3b).
? Portal placement is chosen based on preoperative planning (? Fig. 10.4). For a rotator cuff repair, we routinely use one posterior, one anterior, and one lateral small working portal; one large lateral working portal; and one accessory portal for anchor placement. Care should be taken to keep the skin incision the same size as the cannula. Too large an incision will lead to fluid extravasation around the cannula, increased blood flow, and poor visibility because of the Bernoulli effect.2 To help maintain pressure in the system, place closed cannulas in portal sites not currently in use.
? Posterior portal. Midacromial line approximately 3 cm below the posterior acromion. Just below the ?soft spot.? This is the only portal placed without direct visualization. Keeping this portal low will prevent hinging on the acromion, especially in larger individuals.
? Anterior portal. Made under direct visualization using a spinal needle for localization staying superior and lateral to the coracoid to protect neurovascular structures. Placement depends on how this portal will be used. For instance, in this case of distal clavicle excision, the portal was placed externally in line with the ACJ and internally just below the LHBT. A small diameter, smooth, rigid cannula was used.
Fig. 10.4 Portal placement from external view. Anterior portal with small diameter, smooth, rigid cannula (red asterisk). Anterolateral large working portal with large diameter, rigid, screw-in style cannula (yellow asterisk). Posterolateral small viewing portal (green asterisk). Posterior viewing portal (blue asterisk). Accessory portal for anchor placement (purple asterisk).