Surgery and Fluoro and Arthro Again
Arthrosc Tech. 2019 Oct; eight(10): e1111–e1114.
Arthroscopic and Fluoroscopic Guidance Removal of Intratendinous Cleaved Instrument During Rotator Cuff Repair
Niti Prasataporn
aSection of Orthopedics, Queen Savang Vadhana Memorial Infirmary, Chonburi, Thailand
Kitiphong Kongrukgreatiyos
bDepartment of Orthopedics, Veterans General Infirmary, Bangkok Thailand
Vantawat Umprai
aDepartment of Orthopedics, Queen Savang Vadhana Memorial Hospital, Chonburi, Thailand
Thongchai Laohathaimongkol
aDepartment of Orthopedics, Queen Savang Vadhana Memorial Infirmary, Chonburi, Thailand
Thun Itthipanichpong
aSection of Orthopedics, Queen Savang Vadhana Memorial Hospital, Chonburi, Thailand
cDepartment of Orthopedics, Kinesthesia of Medicine, Chulalongkorn University, Bangkok Thailand
Received 2019 Mar 21; Accustomed 2019 May 20.
- Supplementary Materials
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Video 1 Arthroscopic view from the posterolateral portal while repairing the right rotator cuff revealed visualization of the lost needle tip from the suture passer. A fluoroscope is used for anteroposterior radiography to find the broken needle tip of the suture passer. A No. 18 spinal needle is used percutaneously from the anterolateral part of the shoulder under fluoroscopic guidance to place the tip of the needle at the broken musical instrument and confirmed with internal and external oblique fluoroscopic views. Electrocauterization is used to follow the spinal needle. Later on the rotator cuff is reached, electrocauterization is used to create a small hole in the cuff and followed to the tip of the needle. The cleaved musical instrument tip should exist found, then removed with a grasper. The torn rotator cuff is then repaired with the side-to-side technique and secured to the tendon footprint with an ballast suture.
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Abstract
Instrument breakage during arthroscopic rotator cuff repair is a rare complication of shoulder arthroscopy, especially when the broken instrument has been left within the tendon part of the rotator cuff. We propose a combined arthroscopy and fluoroscopic guidance technique to ease the removal of the broken instrument and repair the torn rotator cuff afterward removal.
Introduction
Arthroscopic rotator cuff repair is now a common procedure among orthopaedic surgeons. Although retained broken musical instrument during arthroscopic rotator cuff repair is a complication not as common as infection, cartilage injury, or fluid extravasation, information technology can make the procedure even more than hard. There is no consensus for a treatment option. A literature review shows mostly case report studies.1, ii, 3, 4 Option of treatments varies ranging from conservative handling, open removal of the musical instrument, and arthroscopic-assisted removal. Retained instrument can migrate to a vital structure or cause recurrent pain and swelling,v so removal of the broken instrument may prevent more serious complications. We suggest a technique to ease the procedure that combines arthroscopic and fluoroscopic guidance to remove the intratendinous-retained foreign trunk and repair the torn rotator gage after the cleaved instrument is removed.
Surgical Technique
Indications
This technique is indicated for patients with cleaved instrument retained at the intratendinous part of the rotator gage (Fig 1).
Intraoperative fluoroscope anteroposterior view of the correct shoulder revealed the broken tip of the suture instrument that was left inside the subacromial space (cherry pointer) while repairing the correct rotator cuff in embankment-chair position.
Positioning
In a case of arthroscopic rotator gage repair, a patient is routinely placed in the beach chair position. A C-arm fluoroscope is placed backside the patient. An anteroposterior shoulder radiograph is taken with the patient's arm placed in neutral rotation. Then the C-arm is horizontally rotated to create internal and external oblique views of the shoulder (Fig 2).
Position of a C-arm fluoroscope to create internal and external oblique views and identify the lost cleaved instrument that was left within the right rotator gage tendon in embankment-chair position. (A) The trajectory of internal oblique view from the C-arm fluoroscope in neutral rotation of the shoulder, from the anteroposterior shoulder trajectory of the C-arm, horizontally rotated the C-arm medially about 20°. (B) The trajectory of external oblique view from the C-arm fluoroscope in neutral rotation of the shoulder, from the anteroposterior shoulder trajectory of the C-arm, horizontally rotated the C-arm laterally near xx°.
Surgical Procedure
After the broken instrument is found by using C-arm fluoroscopy, an anteroposterior image of the shoulder is taken. A No. 18 spinal needle is used, and the tip of the needle is guided percutaneously from the anterolateral role of the shoulder (Fig three) under fluoroscopic guidance toward the broken instrument. Both the internal and external oblique views should be used to confirm the position of the spinal needle tip as information technology touches the broken instrument (Fig 4).
Patient with a broken musical instrument left inside the right rotator cuff tendon in beach-chair position. A No. xviii spinal needle was used percutaneously from the anterolateral office of the shoulder (crimson circumvolve) to locate the position of the cleaved musical instrument under fluoroscopy. Posterolateral portal (PL) was used as a viewing portal and lateral portal (L) was used every bit a working portal.
Intraoperative fluoroscope view of the right shoulder in patient with cleaved musical instrument (red circle) left within the torn tendon while repairing the right rotator cuff in embankment-chair position. (A) The tip of the spinal needle is directed to the cleaved instrument in an internal oblique view. (B) The tip of the spinal needle is directed to the broken tip in external oblique view.
The subacromial infinite is entered arthroscopically. A posterolateral portal is used every bit the viewing portal and a lateral portal is used every bit the working portal (Fig 3). Removal of subacromial bursa by using a four.5-mm DYONICS platinum FR shaver instrument (Smith & Nephew, London, England) and identification of the spinal needle are performed. Turbovac Coblation electro-cauterization (ArthroCare, Sunnyvale, CA) is used to follow the spinal needle to the rotator cuff. Afterward the rotator cuff is reached, electrocauterization tin be used to create a small pigsty in the gage and followed downwards to the tip of the needle (Fig five). The cleaved instrument should be establish close to the tip and removed with arthroscopic grasping instrument (Fig six). Nonetheless, if the broken piece cannot be found, the fluoroscope is used to check for the position of the cleaved piece again and the tip of the needle can be redirected accordingly.
An arthroscopic image from a posterolateral viewing portal of the right shoulder with the broken instrument in rotator cuff tendon. A Turbovac Coblation electro-cauterization (ArthroCare) was used to follow the spinal needle to the rotator cuff. Later the rotator gage is reached, electrocauterization tin exist used to create a small hole in the cuff and followed downwards to the tip of the needle. SSP, supraspinatus.
An arthroscopic image from a posterolateral viewing portal of the right shoulder with the broken in rotator cuff tendon. The tip of the cleaved needle within the supraspinatus tendon is removed past arthroscopic grasper from the lateral working portal.
After the broken piece is removed, the created tendon tear is repaired with a side-to-side sew. And so, the rotator cuff tear is repaired according to familiarity of each surgeon (Video 1).
Postoperative Protocol
The patient is immobilized with an arm sling. Passive range of motion do begins on the first postoperative day. The arm sling is removed and gentle active range of motion exercises begin at iv to half-dozen weeks. At 12 weeks' postoperatively, strengthening exercises and more than aggressive range of move exercises are started. Full sport activities can be resumed after six to 9 months. Advantages/disadvantages, pearls/pitfalls, and indication of the procedure are farther described in Table one.
Tabular array one
Advantages/Disadvantages, Pearls/Pitfalls, and Indication of the Procedure
| Advantages |
| No need for special equipment |
| Minimally invasive procedure |
| Simple arthroscopic procedure |
| Pearls |
| Need an accurate placement of spinal needle |
| Make only one tract of pocket-sized hole in rotator cuff tendon |
| Pitfalls |
| Avert making a large pigsty in rotator cuff tendon |
| Inaccurate placement of spinal needle |
| Spinal needle was moved past arthroscopic instruments |
| Indications |
| Broken musical instrument retention at intratendinous part of rotator cuff tendon during shoulder arthroscopy |
Word
Retained broken musical instrument is a rare complication of shoulder arthroscopic surgery. Oztekin6 reported of a broken arthroscopic probe that was treated via conservative treatment; the patient remained asymptomatic for years. However, symptoms can develop, as Weber and Kauffman7 have shown in regards to the migration of a bioabsorbable screw that was used in Bankart surgery. It moved to the medial border of the scapular, which caused pain and stiffness. Thus, we recommend removal of broken instruments, especially those with sharp cutting edges.
During removal of broken instruments with arthroscopy, both inflow and outflow should be stopped to avert pushing the broken musical instrument further into a nonaccessible surface area.8 Nosotros recommend the same technique. Still, in the subacromial space, with the broken instrument left embedded inside the tendon, maintenance of the arrival fluid while preventing the outflow of fluid is preferred to clear upward the visual field. If the strange torso is visible past the arthroscope, a big grasping instrument, such every bit pituitary rongeur or a big grasper, should exist used to retrieve it.
Lee et al.9 revealed a surgical technique describing the removal of intra-articular strange-trunk from genu, hip, and sacroiliac articulation with an arthroscope. Schmiddem et al.8 reported a case of a missing piece of musical instrument that was left inside the deltoid muscle. However, currently, there is no report of broken instrument that is left inside the rotator cuff. Thus, we written report a technique to observe the missing piece of broken instrument and repair the torn rotator gage.
In a previous commodity past Allum,10 the author recommended pushing foreign bodies that cannot be removed into the nonweight-begetting expanse of the genu joint without performing an arthrotomy procedure because of risk for farther damages to the knee structures. However, we should be concerned almost the future take a chance of osteoarthritis from these foreign objects.
In conclusion, our removal technique is considered as an choice for removing a broken instrument left inside the rotator gage tendon. Information technology provides a minimally invasive approach that allows for removal of retained instruments and avoidance from future undesirable symptoms and complications.
Footnotes
The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE writer disclosure forms are available for this commodity online, as supplementary fabric.
Supplementary Data
Video 1:
Arthroscopic view from the posterolateral portal while repairing the right rotator cuff revealed visualization of the lost needle tip from the suture passer. A fluoroscope is used for anteroposterior radiography to notice the broken needle tip of the suture passer. A No. 18 spinal needle is used percutaneously from the anterolateral part of the shoulder nether fluoroscopic guidance to place the tip of the needle at the broken musical instrument and confirmed with internal and external oblique fluoroscopic views. Electrocauterization is used to follow the spinal needle. Afterward the rotator gage is reached, electrocauterization is used to create a small pigsty in the cuff and followed to the tip of the needle. The broken instrument tip should be found, then removed with a grasper. The torn rotator cuff is and then repaired with the side-to-side technique and secured to the tendon footprint with an anchor suture.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6948112/
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