Burkhart’s View of the Shoulder: A Cowboy’s Guide to Advanced Shoulder Arthroscopy

336 Pages·2006·31.385 MB·English

by  Stephen S. Burkhart MD, Ian K.Y. Lo MD FRCSC, Paul C. Brady MD

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Burkhart’s View
of the Shoulder
A COWBOY’S GUIDE TO ADVANCED
SHOULDER ARTHROSCOPY
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Burkhart’s View
of the Shoulder
A COWBOY’S GUIDE TO ADVANCED
SHOULDER ARTHROSCOPY
STEPHEN S. BURKHART, MD
The San Antonio Orthopaedic Group
San Antonio, Texas
IAN K. Y. LO, MD, FRCSC
Department of Surgery
University of Calgary
Calgary, Alberta
PAUL C. BRADY, MD
Orthopaedic Surgeon
Tennessee Orthopaedic Clinics
Knoxville, Tennessee
Illustrated by Nancy D. Place, MS, AMI
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Acquisitions Editor:Robert Hurley
Managing Editor:Jenny Kim
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© 2006 by LIPPINCOTT WILLIAMS & WILKINS
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All rights reserved. This book is protected by copyright. No part of this book may
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Materials appearing in this book prepared by individuals as part of their official duties
as U.S. government employees are not covered by the above-mentioned copyright.
Printed in the USA
Library of Congress Cataloging-in-Publication Data
Burkhart, Stephen S., 1949–
Burkhart’s view of the shoulder : a cowboy’s guide to advanced shoulder
arthroscopy / Stephen S. Burkhart, Ian K.Y. Lo, Paul C. Brady ; illustrated by
Nancy D. Place.
p. ; cm.
Includes bibliographical references and index.
ISBN 0–7817–8000–4 (alk. paper)
1. Shoulder joint—Endoscopic surgery. 2. Arthroscopy. I. Lo, Ian K. Y.
II. Brady, Paul C. III. Title. IV. Title: View of the shoulder.
[DNLM: 1. Shoulder—surgery. 2. Arthroscopy—methods.
WE 810 B959b 2006]
RD557.5.B87 2006
617.5’720597—dc22
2005036674
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describe generally accepted practices. However, the authors, editors, and publisher
are not responsible for errors or omissions or for any consequences from application
of the information in this book and make no warranty, expressed or implied, with
respect to the currency, completeness, or accuracy of the contents of the publication.
Application of this information in a particular situation remains the professional
responsibility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug
selection and dosage set forth in this text are in accordance with current recommen-
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insert for each drug for any change in indications and dosage and for added warn-
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10 9 8 7 6 5 4 3 2 1
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To Nora. Thanks for sharing the trail with me. Vaya con Dios.
S.S.B.
To my mentors of science, Graham King, Sandy Kirkley, and Cy Frank; to my
mentors of shoulder surgery, Bob Litchfield, Bob Hollinshead, and Evan Flatow;
to Dr. Burkhart, who taught me so much about shoulders and even more about
life; and to my wonderful wife Elaine and our precious daughters, Katelyn,
Madison, and Isabella, the loves of my life.
I.K.Y.L
For all her love and support I thank my wife Jennifer—you’re the greatest. To my
wonderful children (Meredith, Davis, Garrett, and baby on the way) who had to
give up much “Daddy Time” for this endeavor—I say, “You rock, dudes.” Thanks
mostly to the master healer…my Lord Jesus…for giving me the privilege of help-
ing the hurting and letting me learn from the best—Drs. David Martin, Gary
Poehling, and of course Stephen S. Burkhart.
P.C.B.
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Acknowledgments
The authors wish to thank Nancy Place for her magnificent finally, Bob Hurley and Eileen Wolfberg at Lippincott
artwork, her photoediting, and her total dedication to a Williams & Wilkins for believing in the cowboy code and
project that consumed far too many of her weekends; Gina for recognizing that sometimes the book that will make
Ruelas for her tireless efforts in compiling, transcribing, the most difference is the book that is the most different.
and proofreading the manuscript; Bob Merrill for his tech-
nical video support; Jenny Kim for her work as managing Stephen S. Burkhart, MD
editor; Mark Flanders for his work as video editor; and Ian K. Lo, MD
Paul C. Brady, MD
vi
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Contents
Preface ix D.Nonengaging Hill-Sachs Lesion 222
Forewords xv, xvii E. Open Latarjet Reconstruction 223
James C. Esch and Stephen J. Snyder
F. Posterior Bankart and SLAP Repair 226
Messages from the Fellows xix
G. Repair of a Bony Bankart Lesion 227
H.Repair of Reverse Humeral Avulsion of
Glenohumeral Ligament (RHAGL) Lesion 230
PART I. THE BASIS OF COWBOYIN’
I. Repair of Triple Labral Lesion 232
There Ain’t a Horse That Can’t Be Rode, There
J. Arthroscopic Repair of Humeral Avulsion of
Ain’t a Man That Can’t Be Throwed
Glenohumeral Ligament (HAGL) Lesion 234
1 Visualization 3
14 SLAP Repair 236
2 Angle of Approach 7
15 Subacromial Procedures (Non-cuff) 239
3 Creating a Stable Construct 33 A. Arthroscopic Acromioplasty 239
4 Understanding and Recognizing Pathology 53 B. Arthroscopic Distal Clavicle Excision 241
C. Coplaning of Distal Clavicle 242
5 The Tough Stuff: Massive Contracted Adhesed
D.Os Acromiale Excision 243
Rotator Cuff Tears, Subscapularis Tears, and
Biceps Pathology 110 16 Stiffness 245
6 Exposing the Hidden Arthroscopic A. Capsular Release for Adhesive Capsulitis 245
Landmarks 147 B. Capsular Release for Postoperative Stiffness after
Rotator Cuff Repair 246
7 Insurmountable Problems—
C. Manipulation Under Anesthesia 247
Bone Deficiency 156
17 Rotator Cuff 249
8 Gaining Speed and Tricks of the Trade 169
A. Completion of a PASTA Lesion to a Full-Thickness
9 Order of Steps 191
Cuff Tear 249
10 Rotator Cuff Tear Patterns: Repairing a Tear B. Coracoplasty with Nonretracted Subscapularis
the Way It Ought to Be 193 Tendon 250
C. Double-Pulley Technique of Double-Row
11 Postoperative Rehabilitation 203
Repair 251
D.Double-Row Rotator Cuff Repair 252
PART II. PLAYIN' WITH FIRE E. L-Shaped Tear Assessment 254
A Cowboy’s Guide to Cookin’ (Workin’ Smooth), F. Margin Convergence to Bone in a
Smokin’ (Workin’ Fast), and Brandin’ (Leavin’ Reverse-L Tear 255
Your Mark) G. Massive Adhesed Rotator Cuff Tear: Repair by
Modified Double Interval Slide 257
12 Operating Room Set-up 215
H.PASTA Repair: One Anchor Repair 261
13 Instability 217 I. Repair of a Partial (Upper) Subscapularis
A. Arthroscopic Bankart Repair 217 Tendon Tear 263
B. Arthroscopic Latarjet Procedure 220 J. Repair of Bursal Sided Rotator Cuff Tear 265
C. Arthroscopic Treatment of Multidirectional K. Repair of Complete Subscapularis
Instability 220 Tendon Tear 266
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viii Contents
L. Repair of Interstitial Rotator Cuff Tear 268 19 Tricks and Tips 294
M.Reverse L-Shaped Tear: Evaluation and Repair 269 A. Arthroscopic Knot-Tying Using the Sixth Finger
N.Small Bursal-Surface Crescent Tear with Single Knot Pusher 294
Lateral Row Fixation 269 B. Anchor Removal from Glenoid Using OATS
O.The “Bubble” Sign: A Method of Detecting an Harvester 297
Interstitial Rotator Cuff Tear 270 C. Anchor Removal from Greater Tuberosity Using
P. The “Triple Double” Technique of Rotator Cuff OATS Harvester 298
Footprint Reconstruction 271 D.Arthroscopic Suprascapular Nerve Release at the
Q.The Roller-Wringer Phenomenon 274 Suprascapular Notch 298
R. The “Shoestring” Technique of Knotless Lateral E. Compaction Bone Grafting Using OATS
Row Fixation 274 Harvester 301
S. Tuberoplasty: Arthroscopic Treatment of Greater F. Exposing the Scapular Spine 302
Tuberosity Malunion 275 G. Salvaging a Loose Anchor by the “Buddy Anchor”
T. Margin Convergence to Bone: Double-Row Repair Technique 303
of a Small U-Shaped Tear 277 H.The “Suture Weave” Technique of Reloading an
U.Double Interval Slide Technique 279 Anchor 304
V. Routine Margin Convergence Technique 281 I. Pull the Right One: How to Ensure That You Don’t
W.Double-Row Margin Convergence to Bone 282 Unload a Suture Anchor 305
X. Two Anchor Transtendon PASTA Repair via the 20.Assorted Conditions 306
Double-Pulley Technique 284
A. Calcific Tendinitis 306
Y. Anterior Interval Slide in Continuity 286
B. Minicapsular Plication in the Overhead
Z. Anterior Interval Slide 287 Athlete 307
18 Biceps 289 C. Stretching and Strengthening Exercises: Patient
Education Video 308
A. Arthroscopic-Assisted Biceps Tenodesis for
Retracted Biceps Tendon Tear: The Cobra 21. The Future 309
Procedure 289
A. BioForkLok Bankart Repair 309
B. Biceps Tenodesis without Supraspinatus Tendon
B. FiberChain Plus Swivel-Lok Double-Row Rotator
Tear 291
Cuff Repair 309
C. Biceps Tenodesis with Torn Supraspinatus
Tendon 293 Index 311
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Preface
I swore I would never write a book on shoulder had no control, so once we had isolated it as the weak link,
arthroscopy. For those of you who heard me say this, I we had optimized our repair construct.
imagine that this book must come as a bit of a surprise. After I had identified the optimized constructs, I set out
The problem in writing a technical book is that the to devise instrumentation to assemble these constructs
author must overcome two major obstacles. First of all, he or arthroscopically, a task that is much like building a ship in
she must accept the fact that, for a rather extended time a bottle. I began with very simple devices which we gradu-
period, the book will dominate the author’s life. Until the ally expanded and refined, so that now we have a wide
book is finished, the author will not sleep well; the author array of instrumentation and implants that assure a secure
will seem distant and distracted during dinner conversation; arthroscopic repair every time.
and likely become a bit short-tempered from time to time. Obviously, I could never have done this work alone. Dr.
Secondly, in the case of a rapidly developing technical disci- Kiriacos (Kerry) Athanasiou was an invaluable and inspired
pline such as shoulder arthroscopy, the book must be writ- collaborator on the basic research. As for the instrumenta-
ten over a fairly short time period so that it will not be out of tion, I was privileged to work with Don Grafton and his
date by the time it is printed. The challenge to the author is engineering team in developing most of the instruments
to produce a book that is timely yet timeless—an obviously and implants used in the surgical procedures described in
impossible task that creates even further insomnia. this book. Reinhold Schmieding, president of Arthrex, gave
So why bother to write this book? First of all, I knew that me great support and assistance in the development of
I would have tremendous help with this daunting project these procedure-specific devices.
from my outstanding former fellows, Dr. Ian Lo and Dr. Paul Fortunately, I was not facing the open shoulder estab-
Brady, as well as from my immensely talented medical illus- lishment alone. Two of the greatest visionaries in shoulder
trator, Ms. Nancy Place. Furthermore, I never would have arthroscopy, Dr. Steve Snyder and Dr. Jim Esch, also
begun the book without Ian Lo’s repetitive encouragement became my best friends during the early years of shoulder
to write it, plus his promise to be a coauthor. As it turned arthroscopy. Over the years, we have come to be called
out, Paul Brady’s abundant skills at video editing were a per- “The Three Amigos,” and the name has stuck. The value of
fect complement to round out our team. But I’m sure that having loyal friends united in a common cause cannot be
the greatest incentive of all was the opportunity, finally, to overstated. Revolutions are never won by an individual.
consolidate my rather extensive collection of previously One aspect of my work that deserves special mention as a
published concepts, ideas, and research in a single place. The true group effort is that of the disabled throwing shoulder.
way this research came about has a story of its own. Dr. Craig Morgan, Dr. Ben Kibler, and I pooled our ideas and
When I was first beginning to consider the possibility of taught each other a great deal in the process. To a washed-up
arthroscopic rotator cuff repair, I firmly believed that if it baseball player such as myself, this project was a lot of fun.
were to be done, its technique would need to have a sound Another combined effort was my collaboration with Dr.
biomechanical basis to become accepted as a reasonable Joe DeBeer of Cape Town, South Africa, on the conse-
alternative to open repair. My previous training in mechan- quences of bone loss in patients with anterior shoulder
ical engineering was quite useful in providing me the neces- instability. It is a tribute to the state of our current commu-
sary background to devise a series of experiments designed nications systems that two researchers from opposite sides
to determine optimized rotator cuff repair constructs. These of the globe could combine and analyze their data to reach
experiments were set up to identify the weak link in a stan- conclusions with important implications for patients and
dard repair, then to test new constructs and methods that surgeons around the world.
would shift the weak link to a different component of the Now, I’m sure you are wondering why we chose to call this
construct. I would then test new constructs to optimize the book a “cowboy’s guide” to shoulder arthroscopy. I’ll confess
weak link, so that the weak link shifted to another compo- that this was entirely my idea. I’ve often been called a cowboy,
nent of the repair. This sequence of experimentation would and I take that as a compliment. Where I grew up, in central
continue until finally the weak link was shifted to the weak- Texas, there were two ways to do things: the easy way and the
est biologic substrate (i.e., tendon). Obviously, the biologic cowboy way. I was fortunate to grow up with role models
tissue had an intrinsic mechanical strength over which I who always tried to do the right thing, and who passed on
ix
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x Preface
pithy pearls of cowboy wisdom in their everyday speech. For town, it’s hard to imagine that they could have been any-
example, it doesn’t take a genius to figure out what the cow- thing else. To me, Roy Rogers was not an actor on the
boy means when he says, “Never drink downstream from the small screen. He was real; and he was exactly the type of
herd.” But it takes a genius to put it so succinctly. man I wanted to be.
The cowboy spirit has pervaded the personalities of Now more than ever, people feel the need to know
those most responsible for the development of shoulder their history, to know where they came from. But they also
arthroscopy. It seems only fitting that each chapter should need to know their mythology, to know who they are try-
begin with a nugget of cowboy wisdom, paraphrased to the ing to be. Our history tells us who we are, and our myths
best of my memory from my childhood mentors. tell us who we hope to be.
So, here it is. We have tried to write a book that is differ- The West, with a capital W, became the mythical land-
ent from all the rest—a book with a consolidated section scape of America’s home-grown hero, the cowboy. This
on the principles that underlie successful operative shoul- hero, of course, was not the real cowboy, but the mythical
der arthroscopy, followed by an extensive section devoted cowboy, the one that talked slow, rode fast, shot straight,
to details, tricks, and technical tips on the latest arthro- and called every woman “Ma’am.” This cowboy was gen-
scopic techniques. Specifically, we tried to emphasize the erally dependable, but he could be brash and impetuous,
surgical pearls (tricks and tips) that are most useful to sur- and he was easily offended. And once he set out to do
geons, yet are rarely found in books. something, he was tenacious. Relentless. He simply would
This book serves to further a mission to which I have felt not give up.
called from the very beginning. That mission has been to When I attended my first meeting of the Arthroscopy
do all that I can to facilitate the development and teaching Association of North America (AANA) in the early 1980s, I
of shoulder arthroscopy so that it becomes the “new gold had a sensation that I had never experienced during all my
standard” for shoulder surgery around the world. In my years of medical training, a sensation that I had stumbled
opinion, that has already happened; however, because of into the camp of a major group of cowboys. And that’s a
the marked resistance of certain open shoulder surgeons to compliment.
operative arthroscopy, I think that “piling on” is justified. I This group of cowboys, assembled at the infancy of
hope this text, with its liberal use of digital video, will arthroscopic surgery, presented papers on arthroscopic
accelerate the dissemination of the art, the science, and the ligament reconstruction of the knee in broad daylight, and
technique of shoulder arthroscopy. discussed them in an open forum as if these procedures
Finally, I have felt some urgency to finish this book. Over were okay to perform. And it didn’t stop with the knee.
the past year, after treatment for recurrent prostate cancer, I These renegades had the audacity to discuss arthroscopic
have been acutely aware of my own mortality and of the procedures of the shoulder and to predict that such proce-
precious frailty of life. I believe that God wants all of us to dures would someday become the standard of care for the
pass on any of our ideas that have merit and that have the shoulder. And they were so sure of themselves that they
potential to help our fellow man. I would like this book to didn’t care what any of the open surgery experts of the
serve as a tribute to the preservation of worthwhile ideas. day thought.
Philosophically, the ascendancy of shoulder arthroscopy I was so impressed by my first encounter with the
is the only acceptable outcome. It is a significant medical Arthroscopy Association of North America that I immedi-
advancement, and it is gratifying to be a part of that advance- ately applied for membership. Unfortunately, the member-
ment. Two years ago, I tried to crystallize my thoughts on ship committee was less impressed by me than I was by
arthroscopy and arthroscopic surgeons for my Presidential the Association, and they deferred my application, advis-
Address to the Arthroscopy Association of North America. My ing me to reapply in a year. I was crushed. But like the
sentiments have not changed. We’re still a bunch of cowboys. rodeo bronc-riders I admired, I got back on that bucking
horse and tried again, and the second time I was success-
ful. Ironically, I am the first president of the Arthroscopy
PRESIDENTIAL ADDRESS Association of North America who was not accepted to
membership on his first application.
Stephen S. Burkhart, MD What does that mean? That I’m stubborn, tenacious,
Presented at the 22ndAnnual Meeting of the and bull-headed? That I’m an over-achiever? That I can’t
Arthroscopy Association of North America; Phoenix, take a hint? Maybe it means a little bit of all those things.
Arizona; April 26, 2003. But maybe it means I’m a cowboy. After that first rejec-
tion, I could have ridden into the sunset and found
another professional organization to which I could devote
The Arthroscopic Surgeon: Cowboy
my time and energy. That would have been the easy way,
and Scientist
but it wouldn’t have been the cowboy way.
Ladies and gentlemen, members and guests: My heroes As a Texan, I have observed the cowboy way all my life.
have always been cowboys. Growing up in a small Texas The hallmarks of the cowboy are tenacity and self-reliance.