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Rotator Cuff Injury Causes and Treatments

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Organization and consistency are the key to successful shoulder arthroscopy. Certainly, the surgeon must be flexible to deal with a variety of pathologies; however, certain concepts pervade arthroscopic procedures. These include arm positioning (particularly for beach chair), suture management, and shuttling techniques.

Arm position plays an important role in rotator cuff and labral repairs. For rotator cuff repairs, the arm position is varied with some abduction and internal/external rotation to place the greater tuberosity beneath the lateral portal to allow a 90-degree angle of entry into the tuberosity (Fig. 17-15). For labral repairs, the arm is positioned in mild external rotation prior to tying knots to avoid constraining the joint.

Figure 17-9 A, Crochet hook. B, Close-up of crochet hook tip. C, Suture grasper. D, Close-up of suture grasper tip. E, Arthropierce. F, Close-up of Arthropierce tip. (C-F, From Gartsman G: Shoulder Arthroscopy. Philadelphia, WB Saunders, 2003.)

Suture Hooks

Figure 17-12 A, Cuff stitches. B, Close-up view of cuff stitch tips. (From Gartsman G: Shoulder Arthroscopy. Philadelphia, WB Saunders, 2003.)

Figure 17-10 Suture cutter.

Suture management is perhaps the most complex and difficult concept to successfully achieve. Anchors need to be placed in a logical progression, and the sutures need to be tied at specific intervals to avoid tangling suture. Judicious use of accessory and working portals helps to minimize tangles. For example, in a rotator cuff repair, we place all the anchors first and group all the sutures in separate clamps in the anterior portal. Sutures are sequentially passed through the rotator cuff from anterior to posterior. Once all sutures are passed, they are sequentially tied down from posterior to anterior. When tying the suture, two important principles should be kept in mind. First, never tie

Figure 17-11 A, Straight spectrum. B, Curved spectrum.

Figure 17-11 A, Straight spectrum. B, Curved spectrum.

Figure 17-12 A, Cuff stitches. B, Close-up view of cuff stitch tips. (From Gartsman G: Shoulder Arthroscopy. Philadelphia, WB Saunders, 2003.)

suture when another suture is in the cannula. This may result in a tangled mess. Second, a suture grasper or knot pusher should be passed into the joint first to remove any twists that may be present between the two sutures to be tied.

Unlike rotator cuff repairs, all the anchors for a labral repair are not placed prior to passing the suture. This would result in tangled suture. For this reason, generally, the suture from the first anchor is passed through the labral tissue prior to placing the second anchor. Once the suture is passed, the second anchor is placed. The first suture is tied down prior to passing the suture of the second anchor. The same procedure is done with a third anchor. Generally, it is easiest to place the most inferior anchor first and progress superiorly for an anterior labral repair. It is easiest to place the posterior anchor first for a superior labrum anterior to posterior (SLAP) repair if two anchors are to be used.

Suture can be passed through tissue directly or shuttled through tissue indirectly. The ExpresSew, Elite Pass, Cuff Stitch, and several other devices allow direct passage of suture through the rotator cuff, for example. In addition, graspers such as the Arthropierce may pass suture directly through labral, capsular, or rotator cuff tissue. However, suture may also be shuttled through tissue. Devices such as the Caspari or Spectrum may be used to pierce tissue and pass a firm suture such as a single or doubled nylon. This suture can be used to pass the repair suture through the tissue either by tying it directly to the repair suture, using the loop of a doubled suture to lasso the repair suture and pass it, or by using the loop of a doubled suture to pass a second loop (reverse the loop) to pass the repair suture. The final technique is done to facilitate the use of the passing

Shuttle Relay Suture Passing SystemPiriformis Muscle Surgery
Figure 17-15 Anchor placed 90 degrees to tuberosity. (From Gartsman G: Shoulder Arthroscopy. Philadelphia, WB Saunders, 2003.)

device. For example, it is often easier to pierce labral tissue from the capsular surface. When this is done, the two free ends of a nylon suture are passed from the capsular surface of the labrum to the articular surface. To shuttle a suture from the anchor from the articular surface, a second loop of nylon must be passed first using the initial nylon. This places the loop of the shuttle suture on the articular side. This is termed reversing the loop. This concept may be used for many applications.

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Cure Tennis Elbow Without Surgery

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