Dual Row Rotator Cuff Repair using the CHIA PERCPASSER THOMAS P. KNAPP, M.D. Santa Monica Orthopaedic & Sports Medicine Group TM
CHIA PERCPASSER Surgical Technique Dual Row Rotator Cuff Repair using the CHIA PERCPASSER by Thomas P. Knapp, m.d. PATIENT SET - UP The patient is properly identified and brought into the operating room and placed supine on the operating room table. General anesthesia or regional anesthesia is then performed. Antibiotics are given for infection prophylaxis. The procedure can be performed from a beach chair, modified beach chair or a lateral decubitus position. The upper extremity and chest wall are then prepped and draped in the normal sterile manner. A sterile arm holder is used for joint distraction. All anatomic landmarks are drawn on the skin. The glenohumeral joint, subacromial space and proposed portals are injected with a combination of lidocaine and Marcaine with epinephrine after attempting to aspirate prior to injecting. A standard posterior portal is opened using a #15 blade taking care to place the incisions in the Langer lines. ARTHROSCOPIC EXAMINATION & SITE PREPARATION A blunt obturator is used to enter the shoulder. The 4mm 30 arthroscope is placed in the shoulder and an anterior portal is opened using inside-out technique. A diagnostic arthroscopy is performed. A thorough bursectomy must be performed using a motorized shaver and DePuy Mitek VAPR3 electrode. It is important to place a spinal needle percutaneously through a Neviaser portal to make sure that an adequate medial bursectomy has been accomplished. The most important first step in an arthroscopic rotator cuff repair is to identify the type of tear that is present. Is it a simple crescentic type tear, a posterior based or anterior based L-type tear or a U-shaped tear? It is essential to determine if there is a delamination type tear. The surgeon should be able to recognize these types of tears and do the preliminary steps necessary to convert these tears into a crescentic tear that can then be repaired using the CHIA PERCPASSER. Basic principles of a tensionless repair must be adhered to in order to avoid over-tensioning the cuff. A lateral portal is opened adjacent to the acromion localizing the portal to enter at the center on the rotator cuff tear and a cannula is placed. Working from either the lateral or anterior portal in the sub-acromial space the greater tuberosity is cleaned down to bleeding cortical bone using a DePuy Mitek VAPR3 electrode, rasp, motorized Step 1. With medial anchor inserted and anterior blue suture retrieved through anterior portal, an 18g Spinal needle is placed percutaneously through a Neviaser portal location in the desired location through the Rotator Cuff tear. Step 2. Kite (loop) end of CHIA is delivered through spinal needle, spinal needle is then withdrawn and CHIA is grasped and retrieved through the anterior portal. Step 3. Suture is placed through kite (loop) of CHIA.
Step 4. CHIA with suture is withdrawn percutaneously. Step 5. Process is repeated for remaining 3 sutures. Once completed all 4 sutures limbs are percutaneously stored for later retrieval and knot-tying. Step 6. With 2nd lateral anchor inserted and anterior blue suture retrieved through anterior portal, an 18g Spinal needle is placed percutaneously in the desired location through the Rotator Cuff tear. shaver and a motorized burr if necessary. The size of the tear will determine the number of anchors used. This technique will describe a 2-anchor dual row rotator cuff repair but additional anchors may be necessary. The anchors are placed anterior to posterior with the sutures passed before the next anchor is placed. The sutures are always tied from posterior to anterior to avoid having visualization blocked by the remaining sutures. Knot tying is always accomplished through the same portal used to place the anchor. ANCHOR PLACEMENT & SUTURE MANAGEMENT The first SPIRALOK anchor pilot hole is placed at the margin of the articular surface of the greater tuberosity. The pilot hole is created with the SPIRALOK awl followed by the tap. It is important that the proper 45 deadman angle is maintained. The anchor is then placed and inserted to the horizontal laser line ending with the window on the inserter shaft facing the articular surface - this aligns the blue sutures in an anterior/ posterior fashion, and the violet sutures in a medial/lateral fashion. The SPI- RALOK inserter is then removed. The arthroscope remains in the subacromial space for passing of the sutures. Alternatively, the scope can be moved to the glenohumeral joint, allowing intra-articular visualization of suture placement through the rotator cuff tendon. The anterior blue ORTHO- CORD suture is identified and using a suture grasper is pulled out through the anterior cannula. Next an 18 gauge spinal needle is placed percutaneously through the Neviaser portal, directed towards and piercing the supraspinatus tendon. Care should be taken to ensure the spinal needle pierces the cuff tendon through the rotator cuff cable near the tendon edge anteriorly. If the cable is not visible then a 10 to15 mm purchase of tendon is adequate. Visually assure the long head of the biceps tendon has not inadvertently been captured. The CHIA PERCPASSER is then introduced kite (loop) end first through spinal needle and delivered into the sub-acromial space. The spinal needle is then removed and the kite end of the CHIA PERCPASSER retrieved with a grasper through the anterior cannula. (Technical Note: It is important to remove the spinal needle prior to removal of the CHIA PERCPASSER) The suture is placed through the kite (loop) and the CHIA PERCPASSER is removed leaving the 1st suture exiting through the skin. The corresponding blue OR- THOCORD suture end is identified and using a grasper pulled out through the anterior cannula. The 18g spinal needle is again placed percutaneously through the Neviaser portal piercing the rotator cuff tendon posterior to the first suture. The CHIA PERCPASSER is then introduced through the spinal needle and (continued on inside flap)
Step 10. Process is repeated for violet suture strand. Step 11. Lateral anchor post strands are retrieved from percutaneous storage out the lateral portal and simple sutures tied. Step 12. Medial anchor sutures are retrieved from percutaneous storage out the lateral portal and mattress sutures are tied completing the repair. (continued on back) posterior (blue) sutures tied prior to the more anterior (violet) sutures. The blue post limb suture is retrieved from percutaneous storage out the lateral portal joining its mate. These are tied in a simple suture configuration first using a sliding knot followed by half hitches. The excess sutures are cut using the DePuy Mitek Cord Cutter. The more anterior violet post limb suture is then retrieved from percutaneous storage out the lateral portal joining its mate and tied down in a similar manner. The medial row sutures are then brought in pairs (posterior to anterior) from percutaneous storage out the lateral portal and tied in a mattress configuration. The integrity of the repair is assessed from both the sub-acromial space and glenohumeral joint. POST-OPERATIVE PROTOCOL All excess fluid is removed from the shoulder. The deltoid is injected with 10 cc of lidocaine with 30 mg Toradol. The portals are closed with 3-0 Vicryl, followed by steri-strips, sterile Bacitracin, sterile Xeroform, sterile 4x4 s and a MediPore dressing. Always check to ascertain that a radial pulse is present at the end of the case. The patient is then placed into a KnappSak2, awakened and taken to the recovery room. The patient is seen on the second postoperative day for a dressing change and to institute Codman s and passive range of motion exercises. Passive range of motion exercises continue until the six-week mark where active assisted and isometric exercises are instituted. Active strengthening of the supraspinatus is not allowed until the 12-week mark has been obtained. CHIA PERCPASSER CHIA PERCPASSER Suture Passer 214101 SPIRALOK SPIRALOK Anchor 5mm with ORTHOCORD 222986 SPIRALOK Anchor 6.5mm with ORTHOCORD 222988 SPIRALOK Anchor 5mm with ETHIBOND 222964 SPIRALOK Anchor 6.5mm with ETHIBOND 222966 SPIRALOK Anchor 5mm with PANACRYL 222965 SPIRALOK Anchor 6.5mm with PANACRYL 222967 SPIRALOK Awl 222972 SPIRALOK Tap 222975 CordCutter 214646 P/V 900920 Rev A For more information, call your DePuy Mitek representative at 1-800-82-4682 or visit us at www.mitek.com. DePuy Mitek, Inc., 325 Paramount Drive, Raynham, MA 02767. DePuy Mitek, Inc., 2006. All rights reserved. Printed in the USA.
Step 7. Kite (loop) end of CHIA is delivered through spinal needle, spinal needle is then withdrawn and CHIA is grasped and retrieved through the anterior portal. delivered into the sub-acromial space. The spinal needle is then removed and the CHIA PERCPASSER retrieved with a grasper through the anterior portal. The suture is placed into the kite (loop) end and the CHIA PERCPASSER is withdrawn leaving the 2nd suture exiting through the skin. The above steps are repeated for the 2 remaining violet ORTHOCORD suture limbs. Once completed all four ORTHOCORD suture Step 8. Suture is placed through kite (loop) of CHIA. Step 9. CHIA with suture is withdrawn percutaneously. (continued on outside flap) limbs (2 violet and 2 blue) will be percutaneously stored for later retrieval and knot-tying. The pilot hole for the 2nd SPIRALOK anchor is then placed on the lateral aspect of the greater tuberosity utilizing the SPIRALOK awl and tap. The anchor is then placed and inserted to the horizontal laser line with the window on the inserter shaft facing the articular surface - this aligns the blue sutures in an anterior/posterior fashion, and the violet sutures in a medial/lateral fashion. The SPIRALOK inserter is then removed. The posterior blue ORTHOCORD suture limb is pulled out through the anterior cannula. The spinal needle is then introduced percutaneously from just lateral off the acromion and passed through the cuff tendon lateral to the previously placed medial suture row. This can also be accomplished through a Neviaser portal approach. The CHIA PERCPASSER is then introduced kite (loop) end first through spinal needle and delivered into the sub-acromial space. The spinal needle is then removed and the kite end of the CHIA PERCPASSER retrieved with a grasper through the anterior cannula. The suture is placed through the kite (loop) and the CHIA PERCPASSER is removed leaving the suture exiting percutaneous through the skin. This suture will later be the post for knot-tying. These steps are repeated to pass the post limb of the more anterior violet ORTHOCORD suture. The lateral anchor sutures are addressed first with the