Special instrumentation
1. Image intensifier and rotator cuff repair instrumentation.

2) Anesthetic Options: General anesthesia versus interscalene block.

3) Patient Position:
Lateral decubitus position with arms suspended at 30 degrees of abduction and 10 degrees of flexion. Beach chair is not as convenient in terms of utilization of the C-arm.

Surgical Technique
1) The patient is placed in the lateral decubitus position with the head supported in neutral and the arm suspended at 30 degrees of abduction and 10 degrees of flexion.

2) C-arm is brought over the superior aspect of the shoulder with a sterile drape after the arm has been prepped. Calcification is localized with an 18 gauge needle utilizing the C-arm. The needle is left in position.

3) C-arm is moved cephalad but kept sterile.

4) Arthroscopy is performed through a standard posterior superior portal and a standard anterior superior portal. A systemetic diagnostic exam is performed. Articular side abnormalities of the rotator cuff such as a capillary blush are localized with an 18 gauge needle and suture marker technique.

5) Subacromial bursoscopy is performed and the area that was penetrated by the 18 gauge needle under fluro is thoroughly examined. The undersurface of the anterior acromion is also examined for calcification and fraying and indication of impingement.

6) The needle is removed and if calcium exudes as tooth paste from the tendon, it is multiply punctured and balloted with a shaver, as the calcium is suctioned from the joint. This shaver is introduced from a lateral portal.

7) Once all the calcium has been milked from the tendon, the image intensifier is redeployed and utilized to confirm removal of the offending calcium.

8) If the calcification is firm and doesn’t extrude, the extent of the calcification should be localized with multiple 18 gauge needles. This localization can be confirmed with the fluroscopy. Through the lateral portal, a blade is utilized to incise the tendon longitudinally within the confines of the 18 gauge needles. Probes, shavers, and curettes are then utilized to remove the calcification.

9) Depending upon the size of the defect in the tendon, side to side rotator cuff repair may or may not be necessary. This is performed with the scope lateral and the suture passing devices coming from posterior and anterior.

10) Determination for the necessity of acromioplasty is based on both preoperative and operative factors. If the patient demonstrates a Type II or III acromion with anterior calcification in the coracoacromial ligament and preoperative impingement symptoms, it is likely that an acromioplasty would be a valuable adjunct to the calcium removal. This is confirmed at surgery by the arthroscopic appearance of the undersurface of the acromion.

11) Other associated pathology of the glenohumeral joint or the AC joint are treated as appropriate.

12) Calcium deposits within the infraspinatous, subscapularis or biceps tendon can be removed with similar technique. Significant loss of biceps tendon integrity should be treated with soft tissue or bony biceps tenodesis.

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7/8/2006

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