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Arthroscopic Rotator Cuff Repairs Using Suture Anchors
NOVEMBER 1995, VOL 62, NO 5
Home Study Program ARTHROSCOPIC ROTATOR CUFF REPAIRS USING SUTURE ANCHORS
T
he article “Arthroscopic rotator cuff repairs using suture anchors” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Janet S. West, RN, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS(N), professional education specialist, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is necessary to earn two contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is April 30, 1996. Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711
BEHAVIORI\L OBJECTIVES
After reading and studying the article on arthroscopic rotator cuff repairs using suture anchors, the nurse will be able to (I) discuss the diagnosis and treatment of rotator cuff tears, (2) describe perioperative care for patients undergoing arthroscopic rotator cuff repairs using suture anchors, (3) discuss the equipment setup and surgical procedure for arthroscopic rotator cuff repairs using suture anchors, and (4) describe the perioperative nurses’ roles when caring for patients undergoing arthroscopic rotator cuff repairs using suture anchors.
737 AORN JOURNAL
NOVEMBER 1995, VOL 62, NO 5 Farrall
Arthroscopic Rotator Cuff Repairs Using Suture Anchors
S
houlder arthroscopy is a minimally invasive surgical technique that has made significant advancements in the past five years. It began as a procedure used only for diagnosis of shoulder problems but has developed into a surgical technique used for the repair and reconstruction of rotator cuff tears. Improved arthroscopes and arthroscopic equipment now allow surgical team members to visualize intraarticular and subacromial structures of the shoulder joint not seen previously with open surgical procedures. MATERIALS USED IN SHOULDER REPAIRS
Much progress has been made in the use of arthroscopy for treating Bankart lesions and rotator cuff tears (ie, the two types of shoulder injuries most frequently requiring surgical correction). A variety of materials have been used to treat both types of injury. Materials used have ranged from suture only, sutures reinforced with polytetrafluoroethylene (PTFE) patches, surgical staples, surgical screws and washers, polydioxanone bands, polyacetyl wedges and rods, and metallic anchors.' The use of sutures alone is a technically difficult maneuver because of the need to create a curved trough to secure soft tissues to the bone. An additional drawback of using only suture is that the fail-
ure of the repair usually is caused by tearing of the suture through soft tissues. Reinforcing sutures with PTFE patches creates a stronger and more durable repair than suture alone; however, this technique requires an open incision. Surgical staples, screws, and washers are used less frequently because of their tendency to migrate into the shoulder joint, which can lead to cartilage damage, arthritis, and the severing of tendon and bone.2 An alternative to these surgical materials is a titanium-alloy suture anchor. The primary advantages of using suture anchors include increased tissue holding strength equal to or superior to sutures placed through drill holes and decreased surgical time because of the anchors' ease of placement. Suture anchors do not migrate in the shoulder joint, and they do not cause arthritic changes associated with other hardware used for similar purpose^.^ ANATOMY AND PHYSIOLOGY
The glenoid cavity or fossa (ie, the junction of the scapula and humerus) has a capsule volume twice the size of the humeral head and is the most mobile articulation in the body. The group of muscles primarily responsible for stabilizing the shoulder joint is known as the rotator cuff (Figure 1). The rotator cuff is composed of the supraspinatus, infraspinatus, teres minor, and subscapularis muscle groups. Located superiorly to the glenoid cavity is the supraspinatus A B S T R A C T .~ Arthroscopic rotator cuff repairs using titanium-alloy Suture muscle; posteriorly are the infraanchors are a new treatment option for active patients with shoulder spinatus and the teres minor musinjuries. Shoulder arthroscopy and arthroscopic repair procedures are cles; and anteriorly located is the alternative treatments to traditional open surgical procedures for subscapularis muscle. The shoulBankart lesions and rotator cuff tears. Distinct advantages of arthro- der joint often is susceptible to scopic repair techniques include decreased patient tissue trauma injury and degenerative processes and morbidity rates and shortened recovery and rehabilitation peri- because of an absence of stability in these muscle group^.^ ods. AORN J 62 (NOV 1995) 739-750.
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Figure 1 Illustration of the shoulder
anatomy. DIAGNOSIS OF ROTATOR CUFF TEARS
Rotator cuff tears are found more commonly in the supraspinatus tendon. Factors that contribute to damage to this tendon are avascularity of the tendon, age-related changes in collagen, and mechanical trauma.s Pain, crepitus, and weakness in the shoulder when elevating the affected arm are classic symptoms that suggest a possible rotator cuff tear. Increased nocturnal intensity of the pain especially is indicative of such a defect. The acute symptoms may diminish. resulting in patients reporting chronic weakness and discomfort; however, the continued presence of these symptoms leads to eventual disability and chronic pain.6 Onset of shoulder pain may be precipitated by a specific event such as a recent fall onto an outstretched arm. Likewise, sudden, traumatic abduction of the arm may cause a tear by compressing the rotator cuff against the acromial process of the scapula. Fracture, subluxation, or multiple dislocations of the shoulder also may be accompanied by rotator cuff tears. Although rotator cuff tears are found more commonly in patients 45 to 65 years of age, they also can occur in young adults participating in athletic activities or engaging in physically strenuous occupations. Rotator cuff tears occur most frequently in patients’
dominant arms and are 10 times more likely to occur in males than in females.’ Patient evaluation. A physical examination of the patient with a suspected rotator cuff tear includes an assessment of the active and passive range of motion (ROM) of the shoulder joint. A report of increased pain when the arm is moved 60 to 120 degrees in forward elevation or abduction may indicate an impingement syndrome caused by a rotator cuff tear catching under the acromial border. Active elevation that is weaker than passive elevation suggests a significant tear. A positive “drop-arm test” is suggestive of a complete-thickness tear. This test consists of placing the patient’s arm in a position of 90-degrees abduction. If the patient is unable to maintain the indicated position and the ann drops to his or her side, the test is considered positive.8 Diagnostic tests. Routine x-rays can reveal bony changes of the shoulder that may suggest rotator cuff degeneration or pathology. Changes detectable by x-ray include calcar (ie, spurs) at the acromioclavicular joint, an irregular undersurface of the acromion, and calcifications in the rotator cuff and bursa1 tissues.’ Standard x-ray techniques may be enhanced by injecting contrast media into the space between the humeral head and the glenoid cavity. Extravasation of the media into the subacromial region above the rotator cuff indicates a complete tear. This x-ray 740
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method, known as an arthrogram,can be used to rule out or confirm a complete tear of the rotator cuff.’OA conclusive diagnosis most often is c o n f i i e d with a magnetic resonance imaging (MU) scan. Partial and full-thickness tears can be diagnosed accurately based on the results of MRI scans.” TREATMENT OF ROTATOR CUFF TEARS
Standard, conservative medical treatment of rotator cuff tears includes a course of oral anti-inflammatory medications, application of ice, and immobilization of the shoulder for up to four weeks, followed by physical therapy. l2 The goal of physical therapy is to strengthen the muscles that comprise the rotator cuff. Patients who show minimal improvement after prescribed regimens of physical and medical therapies may require orthopedic surgical interventions.13 Older patients. A complete tear of the rotator cuff involves a tear in both the muscle and its underlying capsule. Such a tear may heal with conservative treatment, but shoulder strength is compromised. Full-thickness tears in older patients (ie, greater than 65 years of age) usually are caused by degenerative tissue, and surgical repairs may not be satisfactory. Surgery may provide moderate improvement if it is performed in the acute phase before the edges of the muscle fray and degenerate. Open surgical techniques typically are chosen for older patients if the primary goals are a decrease in shoulder discomfort and a full resumption of patients’ activities of daily living (ADL).14 Patients undergoing open surgical procedures are not allowed to resume ADL or work for at least six to eight weeks after surgery.15 Younger patients. Arthroscopic evaluation and reconstruction are indicated more frequently for younger patients (ie, between the ages of 20 and 35 years), especially those with acute, complete rotator cuff tears. Arthroscopic surgical repair procedures are a preferable option for these active patients because of their desire to return to preoperative ADL and to participate in sports. The use of titanium-alloy suture anchors with these arthroscopic repair procedures is an effective solution for younger patients with small, minimally displaced rotator cuff tears and good bone integrity. Typically, patients undergoing arthroscopic rotator cuff repairs with suture anchors have rapid recoveries and return to work less than a month after surgery.I6
PREOPERATlVL PATIENT CARE
The preoperative phase begins with the patient’s informed decision to have surgery. Patient education is an essential part of the preoperative phase of care, and the surgeon and the perioperative nurse begin patient teaching with a basic description of the planned surgical procedure. Preoperative patient education concerning arthroscopic rotator cuff repairs also includes an explanation of surgical positioning, location of the surgical incisions, the use of general anesthesia, expected benefits, potential risks, and possible complications. The surgeon and the perioperative nurse also explain the expected course of physical therapy and rehabilitation. One to seven days before surgery. The patient reports to the hospital’s ambulatory surgery center (ASC)one to seven days before surgery. The ASC nurse reinforces the earlier teaching and further explains the preoperative preparation process. He or she gives the patient written instructions regarding food and fluid intake restrictions, preoperative discontinuation of anticoagulants, the need to be discharged in the company of a responsible adult, and appropriate clothing to wear after surgery. Preoperative laboratory tests include a complete blood count, urinalysis, and a pregnancy blood test for female patients, when appropriate. All preadmission paperwork is completed on the same day as the patient’s visit to the ASC.The ASC nurse gives the patient a brief overview of the planned immediate postoperative care that includes a description of the type of immobilization to expect, the importance of frequent neurovascular assessments, and the availability of analgesics. The ASC nurse makes a follow-up telephone call to the patient the day before or the morning of surgery to answer any questions, to address any concerns that may have arisen, and to remind the patient about food and fluid intake restrictions and the expected arrival time at the ASC. Patient admission. The patient arrives two hours before his or her scheduled surgery time. An ASC nurse inserts an IV line in the patient’s nonsurgical arm and administers one dose of a prescribed prophylactic antibiotic one-half hour before surgery. The 741
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Figure 2 Surgical setup for an arthroscopic repair of a rotator cuff tear. preoperative nurse removes hair from the surgical site with a depilatory cream and cleanses the area with a povidone-iodine solution. The patient then waits with a friend or family member until time of surgery. Surgical preparation. The circulating nurse and scrub person prepare for the surgical procedure by gathering the necessary equipment and instruments into the OR where the surgery will be performed. Specific items required for proper intraoperative positioning of the patient include a shoulder traction device (Figures 2 and 3), traction weights of 20 to 25 pounds, a sterile traction sleeve, a beanbag and kidney support, an axillary roll, a large pillow, and several silicone gel pads. Instruments. Necessary instruments consist of an instrument set designed specifically for shoulder arthroscopy procedures (Figure 4), a motorized debrider system (Figure 5), instruments used for the arthroscopic insertion of suture anchors (Figure 6), and an available basic orthopedic set with special shoulder retractors (Figure 7) in case the arthroscopic repair cannot be completed satisfactorily. All instrument sets, draping materials, and other
sterile supplies are collected by personnel from the central sterile supply department and deposited in a closed cart, which is delivered to the OR suite early on the day of surgery. Figure 8 shows additional equipment used for arthroscopy, which consists of an endoscopic camera and control unit, a videotape printer, a light source, a video monitor, and an arthroscopic debriding system. Before using the video equipment, the circulating nurse and the scrub person turn on all components of the video system and confirm that everything is functioning properly. Patient interviews. The anesthesia care provider interviews the patient in the preoperative holding area of the ASC while the circulating nurse and scrub person prepare the OR. After the OR preparations are completed, the circulating nurse introduces herself or himself to the patient, verifies the patient’s identification, and conducts a brief preoperative interview. The circulating nurse’s interview and assessment consist of confirming the patient’s understanding of the surgical procedure, verifying the patient’s compliance with the preoperative intake restrictions, 743
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assessing the patient’s level of consciousness, determining the patient’s degree of mobility, and visually inspecting the patient’s skin integrity. The circulating nurse also reviews the patient’s chart for pertinent medical or surgical history information and conf-ms the presence of a valid surgical consent form and recent laboratory test and radiology reports. INTRAOPMRATlvI PATIENT CARE
After the anesthesia care provider and the circulating nurse complete their preoperative patient interviews, they transport the patient to the OR and assist the patient onto the OR bed. The circulating nurse centers all of his or her efforts on being the patient’s advocate. It is the circulating nurse’s responsibility to ensure that the patient receives optimal care because the patient’s ability to use his or her inherent protective reflexes is diminished during surgery.17 For the patient undergoing an arthroscopic repair of a rotator cuff tear, the circulating nurse focuses on prevention of potential injuries related to positioning. Undesirable surgical outcomes include neurovascular compromise of the surgical arm caused by the application of traction, neurovascular compromise of the nonsurgical arm because of pressure in the axillary or ulnar areas, respiratory compromise caused by improper placement of the beanbag or the head support, and impairment of skin integrity from pressure on dependent bony prominences. Intraoperative positioning is a cooperative effort between the circulating nurse, the surgeon, the anesthesia care provider, and other members of the surgical team. During surgery, the circulating nurse periodically monitors the patient’s position to decrease the chance for injury. Surgical preparation. After the patient has been anesthetized, the surgical team members place the patient in a lateral decubitus position. The surgeon preps the patient’s surgical arm by applying povidone-iodine scrub and paint solutions from the top of the affected shoulder down to the fingertips. The surgeon and the scrub person apply sterile drapes including a drainage pouch to collect irrigation fluids and a sterile traction sleeve. The circulating nurse moves the video system where it can be seen easily by the surgeon and surgical assistants. Figure 9 shows a typical OR setup for a shoulder arthroscopic repair procedure.
.
Figure 3 Shoulder traction device and sterile sleeve.
Traction apparatus. After draping is completed, the circulating nurse connects the sterile traction sleeve to a traction apparatus and applies 10 to 12 lb of weight to a primary pulley and 5 to 7 lb of weight to rotational pulleys. He or she applies additional weights to the pulley system in 1-lb or 2-lb increments until sufficient distraction of the shoulder joint is obtained. The amount of weight used for the traction apparatus depends on the size of the patient and is determined by the surgeon. The circulating nurse applies enough weight to the traction device to maintain the surgical arm in 70 degrees of abduction and 10 to 20 degrees of forward flexion without excessively stretching the brachial plexus or the axillary artery. The degree of stretch on the brachial plexus is determined by the amount of tension or ease of movement in the arm. 744
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Figure 4 Shoulder arthroscopy instruments (top) rod and two switching sticks; (bottom, left to right) one 6mm cannula, one blunt obturator, two 8-mm blunt obturators, one 8-mm sharp obturator, and one 8-mm cannula.
Figure 6 Arthroscopic suture anchor insertion set (top to boftom) one knot delivery Instrument, one drill guide, two arthroscopic drill bits, two arthroscopic inserters, one reamer, one suture passer, one knot pusher, and one suture cutter.
Figure 5 Motorized debrider hand piece and power cord used by the surgeon in an arthroscopic rotator cuff repair using titanium-alloy suture anchors.
Figure 7 Rotator cuff repair instruments used in open procedures (left to right) mallet, bone hook, rasp, ruskin, ruler, rongeur, pliers, and two retractors.
The circulating nurse ensures that the weights hang free from the OR bed and do not touch the floor. Surgical procedure. After traction has been established, the surgeon outlines important landmarks (ie, acromion, clavicle, coracoacromial ligament)Ig with a sterile marking pen. The surgeon injects 60 mL of a 5% dextrose and water solution through an 18-G spinal needle placed slightly inferior to the posterolateral aspect of the acromion to facilitate entry of portals into the glenohumeral joint. He or she removes the spinal needle and establishes three portals to accommodate the arthroscope, the outflow cannula, and arthroscopic instrumentation (eg, rod, switching sticks, probe).
First portal. The surgeon establishes the first (ie, posterior) portal by making a small incision with a #11 knife blade and introducing a 5-mm diameter arthroscope cannula with a blunt obturator into the posterolateral side of the glenohumeral joint capsule. He or she removes the obturator and replaces it with a 30-degree lens arthroscope, which is advanced into the joint and used to examine the area surrounding the patient’s biceps tendon. Second portal, The surgeon establishes the second portal by removing the arthroscope and leaving its cannula in place. He or she inserts a rod through the cannula, threads it through the anterior capsule, and places it against the undersurface of the patient’s 745
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anterior skin. The surgeon makes a stab incision over the tip of the rod and then passes the rod through the skin. Next, with the arthroscope cannula still in place, he or she passes a disposable, threaded trocar into the joint capsule on the anterior side and removes the rod. Thir-d portul. The surgeon establishes the third (ie, inferior) portal by making a stab incision and introducing another cannula and obturator slightly inferior to the anterior portal. He or she employs the arthroscope through the posterior portal, uses this portal for the motorized debriding system or instruments, and reserves the inferior portal for irrigation outflow. Arthroscopic exuminution. The diagnostic portion of the arthroscopic procedure begins after the surgeon establishes the three portals. He or she thoroughly examines the contents of the glenohumeral joint including the subscapularis and supraspinatus tendons, the glenohumeral ligaments, and the labrum. The first assistant attaches IV extension tubing and a stopcock to the side port of the arthroscope cannula. The surgeon injects a diluted solution of epinephrine 1: 1,000 strength and 5% dextrose (ie, 1 mL epinephrine in 500 mL of 5% dextrose) to distend the cavity and facilitate visualization of the structures. The surgeon injects the solution into the shoulder joint in 60mL increments until he or she determines the glenoid cavity is sufficiently distended. Sur,qiral repair. The surgeon prepares the surgical site for repair after arthroscopically evaluating the rotator cuff tear. He or she trims frayed edges of the rotator cuff tissue with the motorized debrider introduced through the superior anterior portal. The surgeon carefully manipulates the articular and bursal surfaces of the rotator cuff with a blunt probe to confirm the presence of a full-thickness tear. He or she roughens the greater tuberosity of the glenohumeral rim by using a burr attached to the motorized debrider. This debridement helps vascularize the tendon attachment site and stimulates the attachment of soft tissue to the bone. Application ojsuture anchors. The surgeon uses an arthroscopic suture anchor insertion set and appropriate-sized drill bits and guides to prepare the suture anchor sites. The drill bits and guides are passed through the same cannula used for other arthroscopic instruments. The surgeon uses the tip of the suture passer to pierce soft tissue at the location chosen for suture placement. He or she then advances a #2 nonabsorbable, braided polyester suture through the passer in short pushes. A suture-
Figure 8 * Arthroscopic video system (top shell) television monitor, camera, and video control unit; (second shell) light source and control unit for motorized debrider hand piece and power cord; (third shell) video printer and connecting cables; (bornom shelf) various sizes of disposable tips for the motorized debrider.
grasping instrument is used to retrieve this suture and pull it back through the cannula. The scrub person or first assistant assists the surgeon in threading the suture through the eye of the suture anchor by using the threader tab that is supplied with the anchor. The anchor is placed on its arthroscopic inserter, the surgeon passes the inserter down the cannula, and the anchor is inserted into the drill hole using a smooth motion. To properly seat the anchor, the inserter should not be twisted, bent or wobbled while implanting the anchor. The surgeon applies nominal tension to the suture ends to lock the prongs of the anchor into the bone. After placement of each anchor, the surgeon uses a knot delivery instrument or a knot pusher to advance a slip knot and several locking throws made outside the cannula. The suture now secures the patient’s soft tissue to the bone. Free ends of the suture are threaded through the two holes at the end of the suture cutter. The surgeon passes the suture cutter down the cannula until it reaches the tied knot. He or she advances the cutter sleeve and snips the 746
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Figure 9 Suggested OR setup for a shoulder arthroscopy procedure.
suture at an appropriate length. A typical arthroscopic rotator cuff repair performed with this technique requires placement of two to four suture anchors, depending on the size of the anchor used and size of the rotator cuff tear. Wound closure. The surgeon removes the three portals and uses 4-0 nylon sutures to close the skin incisions. The scrub person applies a dressing of several layers of sterile 4 x 4 gauze pads, and the circulating nurse secures the dressing with silk tape. After the dressing is in place, the scrub person removes the surgical drapes, and the circulating nurse assists the surgeon in removing the patient’s surgical arm from the traction apparatus and sterile sleeve. The surgical team members remove lateral positioning devices and return the patient to a supine position, being careful to maintain proper body alignment. The circulating nurse performs a circulatory assessment of the patient’s hand and fingers and evaluates the patient’s arm for any reddened areas. He or she places the patient’s surgical arm in a sling before
the patient emerges from general anesthesia. The circulating nurse reports pertinent surgical events to the postanesthesia care unit (PACU) nurse via a telephone call at least 20 minutes before the patient arrives in the PACU. The nurse documents pertinent implant information (eg, anchor lot and reorder numbers, size and location of anchors used) in the OR records before the patient leaves the OR. POSTOPRRATlVE PATIENT CARE
After the patient has been extubated, the anesthesia care provider, the surgeon, and the circulating nurse transport the patient to the PACU. The anesthesia care provider gives the PACU nurse pertinent information on the patient’s medical history, reports on the patient’s intraoperative care, and writes discharge orders for the patient. The PACU nurses assess the patient for postoperative pain, possible neurovascular compromise, 9 excessive exudate from the surgical site, 748
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stabilization of vital signs, and return of consciousness. After the patient meets the PACU nurse’s discharge criteria, he or she is transported back to the ASC. Before discharging the patient from the ASC, postoperative nurses continue to assess the patient for postoperative pain and changes in neurovascular status or wound drainage. The patient leaves the ASC with written instructions regarding wound care, immobilization of the shoulder, use of analgesics, application of ice, progression from passive to active R O M strengthening exercises, and signs or symptoms that require immediate medical treatnient (ie, bleeding, pain not relieved by prescribed analgesics, body temperature greater than 100” F [38” C]) before the first scheduled postoperative office visit. The ASC nurse releases the patient to the care of a responsible adult and encourages the patient to call the ASC if questions or complications arise after discharge. The patient may remove the dressing and take a shower 24 hours after surgery. The patient must take care, however, to keep his or her shoulder immobilized while it is in the sling for the first seven days after surgery. A physical therapist begins passive ROM exercises after immobilization is no longer necessary. A patient who has undergone an arthroscopic surgical repair of a rotator cuff tear can anticNOTES I. A T Hecker ct al, “Pull-out
strength of suture anchors for rotator cuff and Bankart lesion repairs,” American Journal elf‘ Sports Medicine
21 (November/December 1993) 874. 2. W A Grana, P D Buckley, C K Yates, “Arthroscopic Bankart suture repair,” American Journal of Sports Medicine 2 1 (May/June 1993) 348353. 3. Hecker et a], *‘Pull-out strength of suture anchors for rotator cuff and Bankart lesion repairs,” 878. 4. D D Wittert, “Rotator cuff Nursin,? 5 tears,” ~I)ilhf~pfdic (July/Aujiust 1986) 17-22. 5. J M Clark, D T Hanyrnan, “Tendons, ligaments, and capsule of
ipate working with a physical therapist for at least three to four weeks after surgery. After t h e patient’s strength and R O M have returned (ie, usually within one to two months), he or she can resume nearly all preoperative ADL, including sports. The surgeon may, however, specify some restrictions regarding overhand throwing and strenuous lifting for up to six months to reduce the chance of a recurrent rotator cuff tear. SUMMARY
There are definite advantages for a patient undergoing an arthroscopic repair of a rotator cuff tear using suture anchors. The surgical procedure is less technical but provides reconstruction comparable to o p e n procedures. Total s u r g e r y time is reduced, smaller incisions are required, and the patient returns to an active lifestyle more rapidly. With the current health care focus on reducing costs and hospital stays, a technique that provides compar a b l e r e s u l t s at b o t h d e c r e a s e d e x p e n s e a n d decreased risk to the patient is a beneficial option. A Lee Anna Farrall, RN, BSN, CNOR. is the supervisor of central sterile supply at Rockingham MmwriaI Hospital, Harrisonhurg, Va. At the time this article was written, she was the OR squad leader foi- orthopedic, gynecological, and plastic surgery specialties at the same institution.
the rotator cuff Gross and microscopic anatomy,” Journal ofBone and Joint Surgery 74 suppl A (June 1992) 713. 6. S J Snyder, “Rotator cuff lesions: Acute and chronic,” Clinics in Sport3 Medicine 10 (July 1991) 596-597. 7. Wittert, “Rotator cuff tears,” 18. 8. Ibid, 20. 9. Snyder, “Rotator cuff lesions: Acute and chronic,” 597. 10. Wittert, “Rotator cuff tears,” 20. 1 I. Snyder, “Rotator cuff lesions: Acute and chronic,” 597. 12. Wittert, “Rotator cuff tears,” 20. 13. L E Paulos, M H Kody, “Arthroscopically enhanced ‘miniapproach’ to rotator cuff repair,” Ameri-
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can Journal of Sports Medicine 22
(JanuaryFebruary 1994) 19-24. 14. T Mulvey, “Anatomy and pathology of the shoulder complex,” Orthopedic Nursing 7 (May/June 1993) 28-35. 15. Wittert, “Rotator cuff tears,” 22. 16. Paulos, Kody, “Arthroscopically enhanced ‘miniapproach’ to rotator cuff repair,” 23. 17. “A model for perioperative nursing practice,” in AORN Siand a d s und Rec0mmendt.d Practices (Denver: Association of Operating
Room Nurses, Inc, 1995) 69-7 1. 18. J 0 Lopez, I Silva, “Shoulder arthroscopy: A diagnostic and therapeutic tool,” AORN Journul48 (December 1988) 1078-1096.
Home Study Program ARTHROSCOPIC ROTATOR CUFF REPAIRS USING SUTURE ANCHORS
T
he article “Arthroscopic rotator cuff repairs using suture anchors” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Janet S. West, RN, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS(N), professional education specialist, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is necessary to earn two contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is April 30, 1996. Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711
BEHAVIORI\L OBJECTIVES
After reading and studying the article on arthroscopic rotator cuff repairs using suture anchors, the nurse will be able to (I) discuss the diagnosis and treatment of rotator cuff tears, (2) describe perioperative care for patients undergoing arthroscopic rotator cuff repairs using suture anchors, (3) discuss the equipment setup and surgical procedure for arthroscopic rotator cuff repairs using suture anchors, and (4) describe the perioperative nurses’ roles when caring for patients undergoing arthroscopic rotator cuff repairs using suture anchors.
737 AORN JOURNAL
NOVEMBER 1995, VOL 62, NO 5 Farrall
Arthroscopic Rotator Cuff Repairs Using Suture Anchors
S
houlder arthroscopy is a minimally invasive surgical technique that has made significant advancements in the past five years. It began as a procedure used only for diagnosis of shoulder problems but has developed into a surgical technique used for the repair and reconstruction of rotator cuff tears. Improved arthroscopes and arthroscopic equipment now allow surgical team members to visualize intraarticular and subacromial structures of the shoulder joint not seen previously with open surgical procedures. MATERIALS USED IN SHOULDER REPAIRS
Much progress has been made in the use of arthroscopy for treating Bankart lesions and rotator cuff tears (ie, the two types of shoulder injuries most frequently requiring surgical correction). A variety of materials have been used to treat both types of injury. Materials used have ranged from suture only, sutures reinforced with polytetrafluoroethylene (PTFE) patches, surgical staples, surgical screws and washers, polydioxanone bands, polyacetyl wedges and rods, and metallic anchors.' The use of sutures alone is a technically difficult maneuver because of the need to create a curved trough to secure soft tissues to the bone. An additional drawback of using only suture is that the fail-
ure of the repair usually is caused by tearing of the suture through soft tissues. Reinforcing sutures with PTFE patches creates a stronger and more durable repair than suture alone; however, this technique requires an open incision. Surgical staples, screws, and washers are used less frequently because of their tendency to migrate into the shoulder joint, which can lead to cartilage damage, arthritis, and the severing of tendon and bone.2 An alternative to these surgical materials is a titanium-alloy suture anchor. The primary advantages of using suture anchors include increased tissue holding strength equal to or superior to sutures placed through drill holes and decreased surgical time because of the anchors' ease of placement. Suture anchors do not migrate in the shoulder joint, and they do not cause arthritic changes associated with other hardware used for similar purpose^.^ ANATOMY AND PHYSIOLOGY
The glenoid cavity or fossa (ie, the junction of the scapula and humerus) has a capsule volume twice the size of the humeral head and is the most mobile articulation in the body. The group of muscles primarily responsible for stabilizing the shoulder joint is known as the rotator cuff (Figure 1). The rotator cuff is composed of the supraspinatus, infraspinatus, teres minor, and subscapularis muscle groups. Located superiorly to the glenoid cavity is the supraspinatus A B S T R A C T .~ Arthroscopic rotator cuff repairs using titanium-alloy Suture muscle; posteriorly are the infraanchors are a new treatment option for active patients with shoulder spinatus and the teres minor musinjuries. Shoulder arthroscopy and arthroscopic repair procedures are cles; and anteriorly located is the alternative treatments to traditional open surgical procedures for subscapularis muscle. The shoulBankart lesions and rotator cuff tears. Distinct advantages of arthro- der joint often is susceptible to scopic repair techniques include decreased patient tissue trauma injury and degenerative processes and morbidity rates and shortened recovery and rehabilitation peri- because of an absence of stability in these muscle group^.^ ods. AORN J 62 (NOV 1995) 739-750.
739 AORN JOURNAL
NOVEMBER 199.5. VOL 62, NO 5 Furrull
Figure 1 Illustration of the shoulder
anatomy. DIAGNOSIS OF ROTATOR CUFF TEARS
Rotator cuff tears are found more commonly in the supraspinatus tendon. Factors that contribute to damage to this tendon are avascularity of the tendon, age-related changes in collagen, and mechanical trauma.s Pain, crepitus, and weakness in the shoulder when elevating the affected arm are classic symptoms that suggest a possible rotator cuff tear. Increased nocturnal intensity of the pain especially is indicative of such a defect. The acute symptoms may diminish. resulting in patients reporting chronic weakness and discomfort; however, the continued presence of these symptoms leads to eventual disability and chronic pain.6 Onset of shoulder pain may be precipitated by a specific event such as a recent fall onto an outstretched arm. Likewise, sudden, traumatic abduction of the arm may cause a tear by compressing the rotator cuff against the acromial process of the scapula. Fracture, subluxation, or multiple dislocations of the shoulder also may be accompanied by rotator cuff tears. Although rotator cuff tears are found more commonly in patients 45 to 65 years of age, they also can occur in young adults participating in athletic activities or engaging in physically strenuous occupations. Rotator cuff tears occur most frequently in patients’
dominant arms and are 10 times more likely to occur in males than in females.’ Patient evaluation. A physical examination of the patient with a suspected rotator cuff tear includes an assessment of the active and passive range of motion (ROM) of the shoulder joint. A report of increased pain when the arm is moved 60 to 120 degrees in forward elevation or abduction may indicate an impingement syndrome caused by a rotator cuff tear catching under the acromial border. Active elevation that is weaker than passive elevation suggests a significant tear. A positive “drop-arm test” is suggestive of a complete-thickness tear. This test consists of placing the patient’s arm in a position of 90-degrees abduction. If the patient is unable to maintain the indicated position and the ann drops to his or her side, the test is considered positive.8 Diagnostic tests. Routine x-rays can reveal bony changes of the shoulder that may suggest rotator cuff degeneration or pathology. Changes detectable by x-ray include calcar (ie, spurs) at the acromioclavicular joint, an irregular undersurface of the acromion, and calcifications in the rotator cuff and bursa1 tissues.’ Standard x-ray techniques may be enhanced by injecting contrast media into the space between the humeral head and the glenoid cavity. Extravasation of the media into the subacromial region above the rotator cuff indicates a complete tear. This x-ray 740
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method, known as an arthrogram,can be used to rule out or confirm a complete tear of the rotator cuff.’OA conclusive diagnosis most often is c o n f i i e d with a magnetic resonance imaging (MU) scan. Partial and full-thickness tears can be diagnosed accurately based on the results of MRI scans.” TREATMENT OF ROTATOR CUFF TEARS
Standard, conservative medical treatment of rotator cuff tears includes a course of oral anti-inflammatory medications, application of ice, and immobilization of the shoulder for up to four weeks, followed by physical therapy. l2 The goal of physical therapy is to strengthen the muscles that comprise the rotator cuff. Patients who show minimal improvement after prescribed regimens of physical and medical therapies may require orthopedic surgical interventions.13 Older patients. A complete tear of the rotator cuff involves a tear in both the muscle and its underlying capsule. Such a tear may heal with conservative treatment, but shoulder strength is compromised. Full-thickness tears in older patients (ie, greater than 65 years of age) usually are caused by degenerative tissue, and surgical repairs may not be satisfactory. Surgery may provide moderate improvement if it is performed in the acute phase before the edges of the muscle fray and degenerate. Open surgical techniques typically are chosen for older patients if the primary goals are a decrease in shoulder discomfort and a full resumption of patients’ activities of daily living (ADL).14 Patients undergoing open surgical procedures are not allowed to resume ADL or work for at least six to eight weeks after surgery.15 Younger patients. Arthroscopic evaluation and reconstruction are indicated more frequently for younger patients (ie, between the ages of 20 and 35 years), especially those with acute, complete rotator cuff tears. Arthroscopic surgical repair procedures are a preferable option for these active patients because of their desire to return to preoperative ADL and to participate in sports. The use of titanium-alloy suture anchors with these arthroscopic repair procedures is an effective solution for younger patients with small, minimally displaced rotator cuff tears and good bone integrity. Typically, patients undergoing arthroscopic rotator cuff repairs with suture anchors have rapid recoveries and return to work less than a month after surgery.I6
PREOPERATlVL PATIENT CARE
The preoperative phase begins with the patient’s informed decision to have surgery. Patient education is an essential part of the preoperative phase of care, and the surgeon and the perioperative nurse begin patient teaching with a basic description of the planned surgical procedure. Preoperative patient education concerning arthroscopic rotator cuff repairs also includes an explanation of surgical positioning, location of the surgical incisions, the use of general anesthesia, expected benefits, potential risks, and possible complications. The surgeon and the perioperative nurse also explain the expected course of physical therapy and rehabilitation. One to seven days before surgery. The patient reports to the hospital’s ambulatory surgery center (ASC)one to seven days before surgery. The ASC nurse reinforces the earlier teaching and further explains the preoperative preparation process. He or she gives the patient written instructions regarding food and fluid intake restrictions, preoperative discontinuation of anticoagulants, the need to be discharged in the company of a responsible adult, and appropriate clothing to wear after surgery. Preoperative laboratory tests include a complete blood count, urinalysis, and a pregnancy blood test for female patients, when appropriate. All preadmission paperwork is completed on the same day as the patient’s visit to the ASC.The ASC nurse gives the patient a brief overview of the planned immediate postoperative care that includes a description of the type of immobilization to expect, the importance of frequent neurovascular assessments, and the availability of analgesics. The ASC nurse makes a follow-up telephone call to the patient the day before or the morning of surgery to answer any questions, to address any concerns that may have arisen, and to remind the patient about food and fluid intake restrictions and the expected arrival time at the ASC. Patient admission. The patient arrives two hours before his or her scheduled surgery time. An ASC nurse inserts an IV line in the patient’s nonsurgical arm and administers one dose of a prescribed prophylactic antibiotic one-half hour before surgery. The 741
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Figure 2 Surgical setup for an arthroscopic repair of a rotator cuff tear. preoperative nurse removes hair from the surgical site with a depilatory cream and cleanses the area with a povidone-iodine solution. The patient then waits with a friend or family member until time of surgery. Surgical preparation. The circulating nurse and scrub person prepare for the surgical procedure by gathering the necessary equipment and instruments into the OR where the surgery will be performed. Specific items required for proper intraoperative positioning of the patient include a shoulder traction device (Figures 2 and 3), traction weights of 20 to 25 pounds, a sterile traction sleeve, a beanbag and kidney support, an axillary roll, a large pillow, and several silicone gel pads. Instruments. Necessary instruments consist of an instrument set designed specifically for shoulder arthroscopy procedures (Figure 4), a motorized debrider system (Figure 5), instruments used for the arthroscopic insertion of suture anchors (Figure 6), and an available basic orthopedic set with special shoulder retractors (Figure 7) in case the arthroscopic repair cannot be completed satisfactorily. All instrument sets, draping materials, and other
sterile supplies are collected by personnel from the central sterile supply department and deposited in a closed cart, which is delivered to the OR suite early on the day of surgery. Figure 8 shows additional equipment used for arthroscopy, which consists of an endoscopic camera and control unit, a videotape printer, a light source, a video monitor, and an arthroscopic debriding system. Before using the video equipment, the circulating nurse and the scrub person turn on all components of the video system and confirm that everything is functioning properly. Patient interviews. The anesthesia care provider interviews the patient in the preoperative holding area of the ASC while the circulating nurse and scrub person prepare the OR. After the OR preparations are completed, the circulating nurse introduces herself or himself to the patient, verifies the patient’s identification, and conducts a brief preoperative interview. The circulating nurse’s interview and assessment consist of confirming the patient’s understanding of the surgical procedure, verifying the patient’s compliance with the preoperative intake restrictions, 743
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assessing the patient’s level of consciousness, determining the patient’s degree of mobility, and visually inspecting the patient’s skin integrity. The circulating nurse also reviews the patient’s chart for pertinent medical or surgical history information and conf-ms the presence of a valid surgical consent form and recent laboratory test and radiology reports. INTRAOPMRATlvI PATIENT CARE
After the anesthesia care provider and the circulating nurse complete their preoperative patient interviews, they transport the patient to the OR and assist the patient onto the OR bed. The circulating nurse centers all of his or her efforts on being the patient’s advocate. It is the circulating nurse’s responsibility to ensure that the patient receives optimal care because the patient’s ability to use his or her inherent protective reflexes is diminished during surgery.17 For the patient undergoing an arthroscopic repair of a rotator cuff tear, the circulating nurse focuses on prevention of potential injuries related to positioning. Undesirable surgical outcomes include neurovascular compromise of the surgical arm caused by the application of traction, neurovascular compromise of the nonsurgical arm because of pressure in the axillary or ulnar areas, respiratory compromise caused by improper placement of the beanbag or the head support, and impairment of skin integrity from pressure on dependent bony prominences. Intraoperative positioning is a cooperative effort between the circulating nurse, the surgeon, the anesthesia care provider, and other members of the surgical team. During surgery, the circulating nurse periodically monitors the patient’s position to decrease the chance for injury. Surgical preparation. After the patient has been anesthetized, the surgical team members place the patient in a lateral decubitus position. The surgeon preps the patient’s surgical arm by applying povidone-iodine scrub and paint solutions from the top of the affected shoulder down to the fingertips. The surgeon and the scrub person apply sterile drapes including a drainage pouch to collect irrigation fluids and a sterile traction sleeve. The circulating nurse moves the video system where it can be seen easily by the surgeon and surgical assistants. Figure 9 shows a typical OR setup for a shoulder arthroscopic repair procedure.
.
Figure 3 Shoulder traction device and sterile sleeve.
Traction apparatus. After draping is completed, the circulating nurse connects the sterile traction sleeve to a traction apparatus and applies 10 to 12 lb of weight to a primary pulley and 5 to 7 lb of weight to rotational pulleys. He or she applies additional weights to the pulley system in 1-lb or 2-lb increments until sufficient distraction of the shoulder joint is obtained. The amount of weight used for the traction apparatus depends on the size of the patient and is determined by the surgeon. The circulating nurse applies enough weight to the traction device to maintain the surgical arm in 70 degrees of abduction and 10 to 20 degrees of forward flexion without excessively stretching the brachial plexus or the axillary artery. The degree of stretch on the brachial plexus is determined by the amount of tension or ease of movement in the arm. 744
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Figure 4 Shoulder arthroscopy instruments (top) rod and two switching sticks; (bottom, left to right) one 6mm cannula, one blunt obturator, two 8-mm blunt obturators, one 8-mm sharp obturator, and one 8-mm cannula.
Figure 6 Arthroscopic suture anchor insertion set (top to boftom) one knot delivery Instrument, one drill guide, two arthroscopic drill bits, two arthroscopic inserters, one reamer, one suture passer, one knot pusher, and one suture cutter.
Figure 5 Motorized debrider hand piece and power cord used by the surgeon in an arthroscopic rotator cuff repair using titanium-alloy suture anchors.
Figure 7 Rotator cuff repair instruments used in open procedures (left to right) mallet, bone hook, rasp, ruskin, ruler, rongeur, pliers, and two retractors.
The circulating nurse ensures that the weights hang free from the OR bed and do not touch the floor. Surgical procedure. After traction has been established, the surgeon outlines important landmarks (ie, acromion, clavicle, coracoacromial ligament)Ig with a sterile marking pen. The surgeon injects 60 mL of a 5% dextrose and water solution through an 18-G spinal needle placed slightly inferior to the posterolateral aspect of the acromion to facilitate entry of portals into the glenohumeral joint. He or she removes the spinal needle and establishes three portals to accommodate the arthroscope, the outflow cannula, and arthroscopic instrumentation (eg, rod, switching sticks, probe).
First portal. The surgeon establishes the first (ie, posterior) portal by making a small incision with a #11 knife blade and introducing a 5-mm diameter arthroscope cannula with a blunt obturator into the posterolateral side of the glenohumeral joint capsule. He or she removes the obturator and replaces it with a 30-degree lens arthroscope, which is advanced into the joint and used to examine the area surrounding the patient’s biceps tendon. Second portal, The surgeon establishes the second portal by removing the arthroscope and leaving its cannula in place. He or she inserts a rod through the cannula, threads it through the anterior capsule, and places it against the undersurface of the patient’s 745
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anterior skin. The surgeon makes a stab incision over the tip of the rod and then passes the rod through the skin. Next, with the arthroscope cannula still in place, he or she passes a disposable, threaded trocar into the joint capsule on the anterior side and removes the rod. Thir-d portul. The surgeon establishes the third (ie, inferior) portal by making a stab incision and introducing another cannula and obturator slightly inferior to the anterior portal. He or she employs the arthroscope through the posterior portal, uses this portal for the motorized debriding system or instruments, and reserves the inferior portal for irrigation outflow. Arthroscopic exuminution. The diagnostic portion of the arthroscopic procedure begins after the surgeon establishes the three portals. He or she thoroughly examines the contents of the glenohumeral joint including the subscapularis and supraspinatus tendons, the glenohumeral ligaments, and the labrum. The first assistant attaches IV extension tubing and a stopcock to the side port of the arthroscope cannula. The surgeon injects a diluted solution of epinephrine 1: 1,000 strength and 5% dextrose (ie, 1 mL epinephrine in 500 mL of 5% dextrose) to distend the cavity and facilitate visualization of the structures. The surgeon injects the solution into the shoulder joint in 60mL increments until he or she determines the glenoid cavity is sufficiently distended. Sur,qiral repair. The surgeon prepares the surgical site for repair after arthroscopically evaluating the rotator cuff tear. He or she trims frayed edges of the rotator cuff tissue with the motorized debrider introduced through the superior anterior portal. The surgeon carefully manipulates the articular and bursal surfaces of the rotator cuff with a blunt probe to confirm the presence of a full-thickness tear. He or she roughens the greater tuberosity of the glenohumeral rim by using a burr attached to the motorized debrider. This debridement helps vascularize the tendon attachment site and stimulates the attachment of soft tissue to the bone. Application ojsuture anchors. The surgeon uses an arthroscopic suture anchor insertion set and appropriate-sized drill bits and guides to prepare the suture anchor sites. The drill bits and guides are passed through the same cannula used for other arthroscopic instruments. The surgeon uses the tip of the suture passer to pierce soft tissue at the location chosen for suture placement. He or she then advances a #2 nonabsorbable, braided polyester suture through the passer in short pushes. A suture-
Figure 8 * Arthroscopic video system (top shell) television monitor, camera, and video control unit; (second shell) light source and control unit for motorized debrider hand piece and power cord; (third shell) video printer and connecting cables; (bornom shelf) various sizes of disposable tips for the motorized debrider.
grasping instrument is used to retrieve this suture and pull it back through the cannula. The scrub person or first assistant assists the surgeon in threading the suture through the eye of the suture anchor by using the threader tab that is supplied with the anchor. The anchor is placed on its arthroscopic inserter, the surgeon passes the inserter down the cannula, and the anchor is inserted into the drill hole using a smooth motion. To properly seat the anchor, the inserter should not be twisted, bent or wobbled while implanting the anchor. The surgeon applies nominal tension to the suture ends to lock the prongs of the anchor into the bone. After placement of each anchor, the surgeon uses a knot delivery instrument or a knot pusher to advance a slip knot and several locking throws made outside the cannula. The suture now secures the patient’s soft tissue to the bone. Free ends of the suture are threaded through the two holes at the end of the suture cutter. The surgeon passes the suture cutter down the cannula until it reaches the tied knot. He or she advances the cutter sleeve and snips the 746
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Figure 9 Suggested OR setup for a shoulder arthroscopy procedure.
suture at an appropriate length. A typical arthroscopic rotator cuff repair performed with this technique requires placement of two to four suture anchors, depending on the size of the anchor used and size of the rotator cuff tear. Wound closure. The surgeon removes the three portals and uses 4-0 nylon sutures to close the skin incisions. The scrub person applies a dressing of several layers of sterile 4 x 4 gauze pads, and the circulating nurse secures the dressing with silk tape. After the dressing is in place, the scrub person removes the surgical drapes, and the circulating nurse assists the surgeon in removing the patient’s surgical arm from the traction apparatus and sterile sleeve. The surgical team members remove lateral positioning devices and return the patient to a supine position, being careful to maintain proper body alignment. The circulating nurse performs a circulatory assessment of the patient’s hand and fingers and evaluates the patient’s arm for any reddened areas. He or she places the patient’s surgical arm in a sling before
the patient emerges from general anesthesia. The circulating nurse reports pertinent surgical events to the postanesthesia care unit (PACU) nurse via a telephone call at least 20 minutes before the patient arrives in the PACU. The nurse documents pertinent implant information (eg, anchor lot and reorder numbers, size and location of anchors used) in the OR records before the patient leaves the OR. POSTOPRRATlVE PATIENT CARE
After the patient has been extubated, the anesthesia care provider, the surgeon, and the circulating nurse transport the patient to the PACU. The anesthesia care provider gives the PACU nurse pertinent information on the patient’s medical history, reports on the patient’s intraoperative care, and writes discharge orders for the patient. The PACU nurses assess the patient for postoperative pain, possible neurovascular compromise, 9 excessive exudate from the surgical site, 748
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stabilization of vital signs, and return of consciousness. After the patient meets the PACU nurse’s discharge criteria, he or she is transported back to the ASC. Before discharging the patient from the ASC, postoperative nurses continue to assess the patient for postoperative pain and changes in neurovascular status or wound drainage. The patient leaves the ASC with written instructions regarding wound care, immobilization of the shoulder, use of analgesics, application of ice, progression from passive to active R O M strengthening exercises, and signs or symptoms that require immediate medical treatnient (ie, bleeding, pain not relieved by prescribed analgesics, body temperature greater than 100” F [38” C]) before the first scheduled postoperative office visit. The ASC nurse releases the patient to the care of a responsible adult and encourages the patient to call the ASC if questions or complications arise after discharge. The patient may remove the dressing and take a shower 24 hours after surgery. The patient must take care, however, to keep his or her shoulder immobilized while it is in the sling for the first seven days after surgery. A physical therapist begins passive ROM exercises after immobilization is no longer necessary. A patient who has undergone an arthroscopic surgical repair of a rotator cuff tear can anticNOTES I. A T Hecker ct al, “Pull-out
strength of suture anchors for rotator cuff and Bankart lesion repairs,” American Journal elf‘ Sports Medicine
21 (November/December 1993) 874. 2. W A Grana, P D Buckley, C K Yates, “Arthroscopic Bankart suture repair,” American Journal of Sports Medicine 2 1 (May/June 1993) 348353. 3. Hecker et a], *‘Pull-out strength of suture anchors for rotator cuff and Bankart lesion repairs,” 878. 4. D D Wittert, “Rotator cuff Nursin,? 5 tears,” ~I)ilhf~pfdic (July/Aujiust 1986) 17-22. 5. J M Clark, D T Hanyrnan, “Tendons, ligaments, and capsule of
ipate working with a physical therapist for at least three to four weeks after surgery. After t h e patient’s strength and R O M have returned (ie, usually within one to two months), he or she can resume nearly all preoperative ADL, including sports. The surgeon may, however, specify some restrictions regarding overhand throwing and strenuous lifting for up to six months to reduce the chance of a recurrent rotator cuff tear. SUMMARY
There are definite advantages for a patient undergoing an arthroscopic repair of a rotator cuff tear using suture anchors. The surgical procedure is less technical but provides reconstruction comparable to o p e n procedures. Total s u r g e r y time is reduced, smaller incisions are required, and the patient returns to an active lifestyle more rapidly. With the current health care focus on reducing costs and hospital stays, a technique that provides compar a b l e r e s u l t s at b o t h d e c r e a s e d e x p e n s e a n d decreased risk to the patient is a beneficial option. A Lee Anna Farrall, RN, BSN, CNOR. is the supervisor of central sterile supply at Rockingham MmwriaI Hospital, Harrisonhurg, Va. At the time this article was written, she was the OR squad leader foi- orthopedic, gynecological, and plastic surgery specialties at the same institution.
the rotator cuff Gross and microscopic anatomy,” Journal ofBone and Joint Surgery 74 suppl A (June 1992) 713. 6. S J Snyder, “Rotator cuff lesions: Acute and chronic,” Clinics in Sport3 Medicine 10 (July 1991) 596-597. 7. Wittert, “Rotator cuff tears,” 18. 8. Ibid, 20. 9. Snyder, “Rotator cuff lesions: Acute and chronic,” 597. 10. Wittert, “Rotator cuff tears,” 20. 1 I. Snyder, “Rotator cuff lesions: Acute and chronic,” 597. 12. Wittert, “Rotator cuff tears,” 20. 13. L E Paulos, M H Kody, “Arthroscopically enhanced ‘miniapproach’ to rotator cuff repair,” Ameri-
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(JanuaryFebruary 1994) 19-24. 14. T Mulvey, “Anatomy and pathology of the shoulder complex,” Orthopedic Nursing 7 (May/June 1993) 28-35. 15. Wittert, “Rotator cuff tears,” 22. 16. Paulos, Kody, “Arthroscopically enhanced ‘miniapproach’ to rotator cuff repair,” 23. 17. “A model for perioperative nursing practice,” in AORN Siand a d s und Rec0mmendt.d Practices (Denver: Association of Operating
Room Nurses, Inc, 1995) 69-7 1. 18. J 0 Lopez, I Silva, “Shoulder arthroscopy: A diagnostic and therapeutic tool,” AORN Journul48 (December 1988) 1078-1096.