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Any portion of the cuff that is reparable to the tuberosity should be attached with number 2 or larger nonabsorbable suture to bone arrhythmia lyrics 6.25 mg coreg order otc. If full mobilization of the rotator cuff will not allow solid repair of the tendon back to the greater tuberosity with the arm at the side blood pressure medication enalapril side effects cheap coreg 6.25 mg with mastercard, then the decision is made to proceed with the latissimus dorsi transfer blood pressure medication for adhd discount coreg 6.25 mg. If a full repair is achieved but the quality of the repair or the tissue quality is fair or poor, we still prefer to perform the latissimus transfer when the likelihood for healing of the primary repair is low and the need for postoperative strength is high and of primary importance to the patient. The incision can be extended proximally as needed for exposure, being careful to change directions when crossing skin creases in the axilla to avoid webbing and excessive scarring in the skin of the posterior axillary crease. Identification of the inferior (lateral) border of the latissimus is the most reliable method for correctly identifying the muscle belly, as there is no large muscle inferior (lateral) to the latissimus on the posterior chest wall. Abduction and internal rotation of the arm provides the best visualization of the tendon at its insertion. Internal rotation of the arm in abduction is necessary for adequate exposure but also brings the radial nerve closer to the latissimus dorsi tendon along its anterior, medial surface. The posterior incision for harvest of the latissimus dorsi runs along the posterolateral border of the latissimus muscle belly, extending to the posterior axillary fold. It may be extended proximally to improve exposure, crossing skin creases at an angle to avoid postoperative contracture. The latissimus dorsi is the most inferior muscle belly running along the posterior and lateral chest wall. The anterior humeral circumflex vessels run along the superior border of the latissimus dorsi tendon and can be a source of significant bleeding if inadvertently cut. Dissection and release of the tendon should be carried out by working from the posterior surface of the tendon, as this keeps all important neurovascular structures anterior (deep) to the tendon. A significant number of patients will have latissimus dorsi and teres major tendons that fuse into one tendon along their superior border where they insert on the humerus, a condition that requires sharp dissection to separate the two. Once the humeral insertion of the latissimus dorsi has been identified, it should be released directly off the bone on the humeral shaft to ensure adequate tendon length for transfer. These locking sutures should be placed as soon as the tendon is released to minimize extensive handling of the tendon itself, which is easily frayed because it has few crossing fibers. These sutures can now be used as traction stitches, and the latissimus is freed from any adhesions on its anterior surface. Do not pull the locking sutures in divergent directions as it will separate the parallel fibers of the tendon. The neurovascular pedicle is identified and freed as well to prevent traction and damage to these structures during the transfer. The pedicle is located on the deep surface of the muscle about 13 cm from the musculotendinous junction. It is best seen and dissected after the tendon is released from its insertion and the muscle is flipped posteriorly, thereby exposing the undersurface of the muscle. Mobilization of the latissimus dorsi for transfer requires dissection of the deep fascial investments of the muscle from surrounding tissues into the chest wall. If this is not performed, maximum excursion of the transfer will not be achieved and the tendon will not be long enough to reach the top of the humeral head. This minimizes the risk of damage to the tendon fibers and facilitates passage of the latissimus into the subacromial space. Using a large Kelly clamp, the latissimus dorsi is passed deep to the deltoid over the posterior surface of the rotator cuff muscles into the subacromial space. Intraoperative photo showing the transferred latissimus dorsi (L) viewed from the posterior chest wall incision on the left shoulder. Cadaveric dissection showing the subdeltoid passage of the released latissimus tendon in the right shoulder. Note the proximity of the axillary nerve (Ax) to the latissimus during this stage of the procedure. Using sharp and scissor dissection and some blunt dissection, the plane underneath the deltoid and superficial to the rotator cuff muscles across the back of the shoulder is developed (about 4 to 6 cm wide) to connect the superior (rotator cuff exposure) and the posterior (latissimus exposure) wounds.
Medially the pectoralis minor is attached blood pressure readings coreg 6.25 mg purchase otc, and laterally there is the insertion of the coracoacromial and the coracohumeral ligaments blood pressure goes down when standing 6.25 mg coreg purchase fast delivery. Proximal to the "knee" of the coracoid and untouched by the osteotomy are the conoid and trapezoid ligaments arrhythmia icd 9 code 12.5 mg coreg. The musculocutaneous nerve enters the conjoint tendon from the medial aspect on its deep surface at an average of 5 cm from the tip of the coracoid (range 1. The axillary nerve runs on the anterior surface of the subscapularis muscle lateral to the axillary artery before it enters the quadrilateral space at the inferior portion of the subscapularis. The anterior inferior glenohumeral ligament lies deep to the middle and lower portions of the subscapularis muscle. This bone loss occurs more frequently with recurrent dislocation than subluxation. A history of pain in the abducted externally rotated arm, pain resulting in a temporarily useless arm (dead arm syndrome), and more subtle variations can occur. Diagnosis is aided by a good clinical examination and imaging showing lesions of passage. The clinician should always assess for axillary nerve injury by checking sensation in the regimental badge area and motor power in the deltoid. Acute impaction may result in anteroinferior glenoid fractures, the so-called bony Bankart lesions. Recurrent subluxation or dislocation may also result in erosion or impaction of the glenoid rim. Recurrent dislocation occurs owing to multiple factors, one of which is the presence of a bony lesion. Following Bankart repair, loss of external rotation is 25 degrees per centimeter of anterior glenoid defect. Redislocation in contact athletes after arthroscopic anterior stabilization occurs more frequently in those with anterior bone loss. Radiographic accuracy and quality are improved when images are taken with fluoroscopic assistance. This patient had recurrent dislocation of his shoulder; note the normal contour of the anterior glenoid on the unaffected side. The bone loss at the anterior border of the glenoid on the side with recurrent dislocation is clearly seen (Cliff sign). We use the Latarjet procedure for all individuals with anterior instability requiring surgery. The skin incision is from the tip of the coracoid extending 4 to 5 cm toward the axillary crease. A self-retaining retractor is used to maintain exposure between the deltoid and pectoralis major. The arm is placed in abduction and external rotation and a Hohmann retractor is placed over the top of the coracoid process. Positioning Under general anesthesia in association with an interscalene block for postoperative pain control, the patient is placed in the beach-chair position. Now adduct and internally rotate the arm to allow exposure of the medial side of the coracoid process. The pectoralis minor is released from this attachment with electrocautery, taking care not to go past the tip of the coracoid and damage its blood supply. A periosteal elevator is then used to remove any soft tissue from the undersurface of the coracoid. This elevator also aids visualization of the "knee" of the coracoid, which is the site of the osteotomy. The coracoid is grasped with a toothed forceps and any remnants of the coracohumeral ligament are released. After release of the pectoralis minor and division of the coracoacromial ligament, the osteotomy is made distal to the coracoclavicular ligaments. The coracoid is delivered onto a swab at the inferior part of the wound and held with a pointed grasping forceps.
The integrity of the acromion and coracoacromial ligament is assessed and preserved hypertension guidelines canada coreg 25 mg order without a prescription. The subscapularis and subjacent capsule are incised from their attachment to the humerus at the lesser tuberosity blood pressure yang normal 25 mg coreg cheap with visa. A 360-degree subscapularis release is carried out while the axillary nerve is protected white coat hypertension xanax coreg 12.5 mg discount. A suction drain is placed just anterior to the subscapularis and led out through a long subcutaneous track to exit the skin of the lateral arm. Continuous passive motion is used for 36 hours for all reconstructions except for the Delta or reverse arthroplasty. Incise susbscapularis and capsule from insertion to lesser tuberosity, preserving maximal length of tendon. If the glenoid is rough and eroded medially, but not superiorly, and if the infraspinatus and subscapularis are intact or robustly reconstructable, and if the patient has soft glenoid bone (as in rheumatoid arthritis), consider inserting a prosthetic glenoid component. If glenoid arthroplasty has been performed, select the humeral head prosthesis with the appropriate diameter of curvature for the glenoid. If glenoid arthroplasty has not been performed, select the humeral head prosthesis with the diameter equal to that of the resected head. Marking the humeral osteotomy at 45 degrees with the reamed axis of the shaft and in 30 degrees of retroversion. Measuring the resected head to determine the diameter of curvature and the height. Impaction grafting of the medullary canal to achieve a secure press-fit without jeopardizing the strength of the diaphyseal cortex. If abutment occurs, perform smoothing on the humeral side, preserving the integrity of the arch. Smoothing of the greater tuberosity lateral to the articular surface of the prosthetic humeral head. Balancing the soft tissue tension: 40 degrees of external rotation (D), 50% posterior translation (E,F), and 60 degrees of internal rotation in 90 degrees of abduction (G). Lyse adhesions and remove bursa from the humeroscapular motion interface, protecting deltoid, acromion, and residual cuff tissue. Tag any potentially reparable elements of the cuff that are identified, for later use. Incise the subscapularis and capsule from insertion to lesser tuberosity, preserving maximal length of the tendon. The inferior aspect of the metaglene should align with a line extended from the axillary border of the scapula. When the arm is pulled distally, the plane of the humeral cut should pass just below the inferior glenoid. Glenoid Preparation Dissect the capsule from the anterior glenoid down to and around the inferior pole so that the upper axillary border of the scapula can be palpated and seen, releasing the origin of the long head of the triceps as necessary. Check radiographs and exposed glenoid to identify abnormal glenoid anatomy (eg, superior, inferior, anterior, posterior, inferior or medial erosion, as well as defects from previous surgery [such as earlier arthroplasty]). Note the relation of the inferior glenoid lip to the axillary border of the scapula. Mark a point 13 mm anterior to the posterior rim of the glenoid and 19 mm superior to the inferior glenoid rim. Palpate the anterior and posterior aspects of the axillary border of the scapula and rotate the metaglene so the inferior screw hole is centered over the axillary border. Recall that the inferior locking screw makes a 16-degree angle with the central peg. Using a drill guide, drill a hole for the inferior locking screw, checking frequently to ensure that the drill is in bone by pushing on the drill while it is not rotating. The glenoid guidewire is inserted 19 mm up from the inferior edge of the glenoid and 13 mm anterior to the posterior glenoid border. Verifying the intraosseous position of the inferior drill hole by direct palpation. Inspect the inferior aspect of the glenoid, removing any bone that may abut against the humeral polyethylene component. Adequacy of bone resection can be verified by placing a trial polyethylene humeral component over the glenosphere and making sure it can be adducted fully, recalling that the humeral cup makes a 65-degree angle with the humeral shaft. The desired position of the anterior screw exiting deep in the subscapularis fossa.
The subscapularis is incised about 1 cm medial to its insertion phase 4 arrhythmia cheap 12.5 mg coreg with amex, leaving a stout cuff of tissue laterally (arrow) for subsequent repair blood pressure medication swollen ankles buy generic coreg 12.5 mg. Blunt dissection inferiorly blood pressure medication and st john's wort buy cheap coreg 25 mg line, where the subscapularis muscle is not adherent to the capsule, facilitates finding the plane of separation between the subscapularis and anterior capsule. The capsule is sharply incised, taking care not to damage the humeral head cartilage below. The approach is the same as in the Bankart procedure described and involves dissection of the subscapularis from the anterior glenohumeral capsule. Unlike the inferior capsular shift procedure, the T-plasty involves a medially based capsular incision at the glenoid margin. The laterally based inferior flap of capsule is advanced superiorly and medially and secured to the glenoid rim. The T capsulotomy is made two thirds from the top of the capsule, with the vertical component adjacent to the glenoid rim. A deltopectoral approach to the shoulder is used and the strap muscles are retracted medially to expose the subscapularis tendon. A horizontal capsulotomy is now made in the middle of the capsule extending medial to the glenoid rim. The subscapularis is divided horizontally in line with its fibers at the junction of the upper two thirds and lower one third. The capsule is elevated off the glenoid subperiosteally to allow for superior and inferior capsular advancement. The laterally based inferior flap is shifted superiorly and secured to the intra-articular portion of the glenoid rim using transosseous sutures to attempt to recreate the labral "bumper. Because the subscapularis tendon is not detached, active assistive rehabilitation exercises are begun immediately on postoperative day 1, and rehabilitation is progressed more rapidly. The procedure was designed to treat involuntary inferior and multidirectional instability of the shoulder that could not be addressed by repair of the anterior glenoid labrum alone (the Bankart procedure). The subscapularis tendon is incised about 1 to 2 cm medial to its insertion at the lesser tuberosity, leaving an adequate cuff of tissue for repair. The subscapularis consists of both a superior tendinous portion (two thirds) and inferior muscular (one third) portion. The arm should be in a position of adduction and external rotation during this inferior dissection, and great care is taken to protect the axillary nerve. By placing traction on the capsular tag sutures in a superior and lateral direction, the axillary pouch should be obliterated when an adequate amount of capsular dissection has been performed. It is important to release the inferior capsular attachments to the humerus, which have a broad insertion inferior to the articular surface. The medial insertion of the glenohumeral ligaments and glenoid labrum should then be assessed for avulsion or tear. Once secure fixation to bone is achieved, the capsule is shifted superiorly and laterally and the nonabsorbable sutures are passed through the capsule from an intraarticular to extra-articular location. It is important to place the sutures as close to the glenoid rim as possible so that the capsule is not shortened by medial plication. A bimanual technique can be used in which one needle driver is used to pass the suture and a second to "catch" the needle on the extra-articular side. The sutures are then tied on the extra-articular side to secure the capsule to the glenoid rim. In the inferior capsule shift procedure, the laterally based capsular incision is continued inferiorly using tag stitches on the released anterior capsule to apply traction. Release of the dual inferior capsular attachment, allowing a complete shift of the capsule. An anterior crimping (barrel) stitch is used to decrease the redundancy of the anteroinferior capsule. Once tied, the barrel stitch reduces anterior medial capsular redundancy and an anterior inferior bolster is created. The anteroinferior capsule is advanced superiorly and reattached to the capsular sleeve preserved on the humeral neck. The superior flap is sewn to the inferior flap to reduce volume and increase strength. The rotator interval capsule is palpated between the subscapularis and supraspinatus tendons. Once the medial instability repair is complete, attention is directed to lateral repair of the capsule to the remaining cuff of tissue at the humeral neck.