Rototor Cuff Repair & Open Acromioplasty – Dr. Hawkins
Positioning: Supine, 45o beach chair with head in Mayo headrest. Tip the legs up 20o, then tip the back up 25o to get 45o. The arm should be resting on the armrest. Head in the middle.
Prepping and Draping:
Shave the area. 10×10 steri-drape across the neck. Mark off the acromion and AC joint. The incision is made transversely in line with the fibers, about 1 cm medial to the lateral border of the acromion, and is about 10-12 cm long.
Blade through the skin, then cautery as soon as you get through the epidermis. When you get into the subcutaneous tissue, use the Mets or Mayo scissors to get under the fat and gritty subcutaneous tissue onto the fascia overlying the deltoid. The commonly made mistake is to go too deep and get into the deltoid muscle. You want to preserve the fascia over the deltoid muscle for the later repair. Then undermine the medial and lateral flaps, and insert two galpi retractors.
Identify the acromion and clavicle (and AC joint). Use the cautery and cut right down to bone about a centimeter back from the anterior edge of the acromion. Carry this dissection down to bone right over the AC joint and potentially over the clavicle. This medial part does not need to be done if the distal clavicle is not going to be resected. Cauterize over the lateral edge of the acromion and through the superficial fibers of the deltoid, enough to get a bit of a trough going in the deltoid. Then use a blunt instrument – tips of the mets, or a bristow, to split the deltoid fibers down to the bursal tissue. Carry this right back to the lateral edge of the acromion.
There are now two fasial/muscle/periosteal flaps – the anterior and the posterior. Do not elevate the posterior flap off the acromion – it is not necessary to expose the posterior part of the acromion to do the acromioplasty. Elevate the anterior flap subperiosteally using the cautery. When the anterior flap reaches the anterior surface of the acromion, you will encounter the coracoacromial ligament, through which the acromial branch of the thoracoacromial trunk travels – it will always bleed when you take the ligament insertion off, so anticipate this and be ready for bleeding.
Hawkins sometimes seems to identify the AC joint, particularly if the distal clavicle needs to be resected, and he may cauterize right through the superior capsule. If this needs to be exposed, you can carry the subperiosteal dissection both anteriorly and superiorly and take the lateral 1.5 cm of the clavicle off with the oscillating saw. Cut through the bone, and then use the cautery to release the soft tissues from the undersurface of the bone. The key here is to grab the distal bone with a towel clip and lift it up, using the cautery to release it.
To do the acromioplasty, you need to insert a Bristow under the acromion along the curved undersurface to protect the rotator cuff. Then use the surg-airtome to cut the undersurface off. With the patient sitting at 45o, the blade should be almost vertical.
Use a 15 blade to incise through the bursal tissue that you see under the deltoid after bluntly dissecting through the deltoid. This should expose the cuff defect. Externally and internally rotating the shoulder should bring the edges of the cuff tear into view.
To give you a better look under the acromion, start with the acriomoplasty. Then you can put in the Gerber retractor or use a Bristow elevator to lever down the head.