Publicado em: 25 de junho de 2020 por Dr. José Carlos Garcia Jr. Categorias: Lesões Ombro
A deformidade ou doença de Sprengel é um distúrbio congênito raro no qual a omoplata (escápula) é muito alta. A escápula anormal também é anormalmente conectada à coluna por um osso anômalo, omovertebral, ou uma fibrose, restringindo o movimento do ombro e cintura escapular. A escápula pode apresentar deformidade, sendo menor que o normal(displásica) e em posição alterada. A deformidade de Sprengel pode ocorrer isoladamente ou em associação com outras anormalidades. Essa lesão geralmente está presente no nascimento (congênito), embora possa não se tornar aparente até que o indivíduo atinja a idade adulta. A causa da deformidade de Sprengel é desconhecida.
Em alguns casos, a posição da escápula e/ou a amplitude de movimento do ombro podem estar alterados.
No seu tratamento cirúrgico o osso omovertebral ou seu equivalente fibroso deve ser removido.
Existem vários procedimentos cirúrgicos que podem ser usados para tratar indivíduos com deformidade de Sprengel. Os dois mais conhecidos são a cirurgia de Green e o procedimento de Woodward, entretanto a escapuloplastia de Copeland associada ao morcelamento clavicular e procedimentos de partes moles parece ser o mais efetivo tratamento para crianças. Em deformidades com pacientes de maior idade outras opções devem ser consideradas e individualizadas.
O Nervo Acessóro espinhal é responsável pela inervação do músculo Trapézio. Sua origem na evolução remonta os músculos branquiais dos peixes. É inervado pelo XI par craniano, por isso mesmo tetraplégicos podem mover o ombro.
Divide-se em três porções porções superior, média e inferior.
o Trapézio Superior origina na região occipital e em vértebras cervicais altas. Sua inserção é na borda clavicular posterior, funcionando como elevador da cintura escapular.
O Trapézio Médio origina-se nas apófises espinhosas da 7ª vértebra cervical e das primeiras vértebras torácicas., insere-se na borda interna do acrômio e na borda posterior da espinha da escápula. É responsável pela retração da escápula.
Trapézio baixo tem origem nas apófises espinhosas das últimas vértebras torácicas, sua inserção fica na porção média da espinha da escápula. Sua função é a retração e depressão da escápula.
A hipotrofia do músculo trapézio pode causar grave dificuldade para elevar o membro superior além de 90° e dor. A escápula alada geralmente é observada na abdução, podendo estar menos evidente na elevação.
Entretanto, deve-se ter cuidado pois outras lesões neurológicas ou desbalanços podem causar discinesias e escápula alada. O músculo peitoral menor, trapézio, elevador da escápula, romboide menor e maior.
Seu tratamento depende da gravidade do acometimento indo desde o clínico até o cirúrgico.
A cirurga de tripla transferência muscular. pode usar Rombóide Menor, Elevador da Escápula e Grande Dorsal. Outras transferências do Rombóide Menor, Rombóide Maior e Elevador da Escápula podem também ser feitas.
O Nervo Torácico longo é responsável pela inervação do músculo serrátil anterior tem sua origem nas laterais das costelas superiores e sua inserção por toda a borda medial da escápula. Sua função é a protração e rotação lateral ou externa da escápula, além de sua estabilização. O desbalanço mecânico causado pela insuficiência do músculo serrátil anterior pode levar a uma escápula alada com insuficiência mecânica da cintura escapular. Muitas vezes pode haver perda da estabildade dos movimentos do ombro secundária à lesão do nervo torácico longo causando grave discinesia escapular e restrição dos movimentos associada a dor.
Entretanto, deve-se ter cuidado pois outras lesões neurológicas ou desbalanços podem causar discinesias e escápula alada. O músculo peitoral menor, trapézio, elevador da escápula, romboide menor e maior.
A lesão ou insuficiência deste nervo pode necessitar desde tratamento clínico até o cirúrgico.
No tratamento cirúrgico, a transferência do tendão do músculo peitoral maior para a borda ânteroinferior da escápula é a melhor opção.
Objective: This study demonstrates the new technology of the robotic telesurgery on three brachial plexus reconstructions. We also discuss the implications, problems, and benefits of robotically assisted brachial plexus surgery.
Methods: After the first experimental experience in a cadaveric model, the authors performed three brachial plexus reconstructions. The surgery followed the traditional brachial plexus approach. From the moment that nervous sutures would be performed, the Da Vinci® (Intuitive Surgical™, Sunnyvale, CA) equipment was docked at the patients, positioned behind the patient’s head, and the microsurgical steps were performed by using robotic telemanipulation.
Results: The first procedure was performed in a cadaver to gain experience and establish a surgical protocol by using the robot. In all the three living patients, the goals of the surgical procedure were achieved using the telerobotic manipulation.
Conclusion: Robot-assisted surgery allows performance of high-dexterity surgical operations with the help of robotic arms and it improves the surgery due to tremor filtration, motion scaling, and ergonomics. The benefit of using the robot on microsurgery was reached, but its entire potential was not realized because the instruments used on those first experimental and clinical cases were not specifically designed for microsurgery.
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The applications of robotic surgery have quickly spread into a variety of surgical fields. Interest in robotic endoscopic surgery is high because of the small size of the incisions, cosmetic advantages, less invasive surgical techniques, decreased scar tissue, shorter duration of hospitalization and increased cost-effectiveness. We will describe an anatomical feasibility study and a clinical test case of robotically assisted pedicled transposition of the latissimus dorsi muscle.
A escápula alada é o resultado de desbalanço mecânico grave da cintura escapular.
A escápula alada pode ter muitas causas, sendo resultado de alterações musculares, hiper/hipotonia alterações neurológicas e deformidades. Algumas das formas mais evidentes da discinesia são decorrentes da lesão ou patologia do nervo torácico longo. Nessa lesão há comprometimento da estabilização contra o gradil costal e da rotação inferior da escápula, ficando evidente na manobra de flexão a 90º de elevação contra a parede. Outras lesões neurológicas como a lesão do nervo acessório espinhal, decorrente de esvaziamento cervical após retirada de tumor cervical, e a síndrome do desfiladeiro torácico podem causar escápula alada com grau menor de deformidade.
Quando decorrente de Síndromes compressivas do plexo braquial mesmo as discinesias mais leves podem ser fonte de dor e desconforto, principalmente na síndrome do desfiladeiro torácico e síndrome do peitoral menor.
Alongamentos, medicações neurotrópicas, RPG, fisioterapia, transferências musculares e liberações neurológicas são os tratamentos recomendados para a melhora dessas alterações.
Thoracic outlet syndrome(TOS) is a debilitating condition, impairing the function of the upper limb, and can be considered as an entrapment of neurovascular structures dedicated to the upper limb. Its open treatment uses large approaches and to this date just structures under the clavicle have been endoscopically approached.
The purpose of this technical note is to describe an endoscopic all brachial plexus decompression of at all possible entrapment areas, between the neck and the arm.
Thoracic Outlet Syndromes(TOS) is a debilitating condition, impairing the function of the upper limb, and can be considered as an entrapment of neurovascular structures dedicated to the upper limb1,2.
The entrapment can be situated at different levels, between the neck and the arm, including the interscalenic triangle, the upper border of the first rib (by the rib itselt or a hypertrophic transverse cervical process with or without fibrous bands) the costo clavicular space, the retro coracoid, pectoralis minor and the penetration point of the neurovascular bundle at the level of the brachialis fascia1. The exact location of the entrapment can be difficult to access as well as the etiology of the compression and the structures involved like brachial plexus, subclavicular vein and artery.
The TOS pathophysiology is multifactorial, including anatomical variations, cervical rib, fibrous bands, anomalous muscles, joint hypermobility, or biomechanical dysfunctions of the neck and scapular girdle related to labor, post-traumatic or sports gesture3. On this scenario the bony compression by a narrowing space between the clavicle and the first rib or a cervical rib, that was previously considered the main entrapment cause, will be responsible for just 20-30% of the cases1,2.
TOS diagnosis remains difficult and controversial. No consensus have been reached to establish objective criteria proving the diagnose of TOS. Indeed it is mainly dynamic compression, therefore dynamic assessments seem to be more adapted, eventhough these assessments may be difficult or even present high rates of false negative results4.
Among the TOS types, the most common is the neurogenic(nTOS) one. Some of the clinical characteristics of the nTOS are pain, paraesthesia and weakness4.
The pain is usually neuropathic, affecting the posterior cervical area, trapezius and pectoral regions. It may also be felt on the entire upper limb. Weakness may also be described by these patients 1,4,5.Reports of pain, weakness and paraesthesia associated with irritative maneuvers will strongly suggest the nTOS diagnosis4,6.
Complementary exams can be used, mainly to exclude other diagnoses (i.e roots compression at the cervical spine, peripheral nerve tumors, distal entrapment syndromes). One of the main situation that would suggest nTOS is the dynamic arterial subclavian duplex velocity assessment. This assessment compares the differences between the arterial subclavian flux in rest and during the stress maneuvers. The proximity between the brachial plexus and subclavian artery can provides one with an indirect suggest a brachial plexus entrapment6-8. It can be useful even in patients with no vascular apparent compromise. Trained radiologists are also able to evaluate this entrapment by analysing the amont of fat tissue around the brachial plexus, and comparing its size between the resting and abduction and external rotation of the shoulder
The classical treatment for these patients is conservative6,7, consisting on pharmacological measures, shoulder girdle rehabilitation and ergonomic readjustment for working or exercising1,7.
Surgery is indicated in cases refractory to the conservative treatment, after a long period of rehabilitation8. Surgical techniques should be directed to the structures that cause this entrapment. The most common procedures mention the resection of the cervical rib, scalenectomy and release of the pectoralis minor tendon next to the coracoid7-10.
Endoscopic soft tissue decompression of the brachial plexus has been performed initially in cadaveric models11. In vivo to this moment only subclavicular decompression of the brachial plexus was performed. The suprascapular space had been released so far through the trans trapezial portals, starting from a release of the suprascapular nerve, and moving proximaly to the interscalenic area, without performing any scalenectomy, nor exposing the phrenic, long thoracic and dorsal scapular nerves4.
The purpose of this technical note is to describe an endoscopic brachial plexus decompression on suffering from nTOS at all possible entrapment areas, between the neck and the arm.
The procedure is performed in lateral decubitus under general anesthesia associated with interscalene plexus block. The upper limb – is set up with a traction allowing a positionning of the shoulder in anterior elevation, and slight abduction of respectively 30° and 15°.
A standard bipolar radiofrequency was used, VAPR®(DePuy Synthes, Raynham, USA). Saline infusion is used, just by gravity through 4-way equipment with no pump.
The first step is the insertion of the video scope through the posterior portal for joint and subacromial space evaluation. In the bursal space, the lateral portal is done, followed by bursectomy. The coracoacromial ligament is identified and removed. The optic passes to the lateral portal, coracoid process and pectoralis minor tendon is identified. An anterioinferior portal is done in the axillary line, about 2 cm below the coracoid lateral to the conjoint tendon is done with the help of a needle under visualization control.
The coracoid is exposed using radiofrequency device through the anterioinferior portal, dissecting the space posterior to the pectoralis major, progressively moving medially until the pectoralis minor insertion can be visualized and released. The upper part of the pectoralis minor is exposed, along with the cords of the brachial plexus coming from a lateral and medial areas. Under visualization control, the medial portal is made, 5 cm medial to the anterioinferior portal. The optic is moved to the anterioinferior portal(Fig. 1), then the radiofrequency device is inserted through the medial portal and is used to detach the pectoralis minor tendon, allowing the visualization of the terminal branch of the musculocutaneous nerve and the neurovascular bundle.
At this step, three structures are visualized going from the brachial plexus towards the deltoid muscle: lateral pectoralis nerve, thoracoacromial artery branch and cephalic vein. If fibroses or adhesions are found they can be released in this region.
The costoclavicular space is then reached. Using the lateral pectoralis nerve as a landmark, the plane between the brachial plexus and the subclavian muscle is identified. Anatomical variations of the subclavian muscle or the presence of the pectoralis minimus muscle may entrap the plexus in this area. Radiofrequency myotomy of the subclavius muscle can be performed until the clavicle is reached(Fig. 2). Using the soft tissue shaver(Razek, São Carlos, Brazil) with no aspiration will increase muscle resection and increase the cervical space view. In some selected cases (distance between the plexus clavicle less than 1 cm), partial resection of the clavicle may also be performed by using a bony shaver.
Through this same portal, the optics advances proximally to the cervical region between the plexus and the clavicle. Using a blunt dissector, the first cervical portal is done, just above the clavicle, supraclavicular portal, over the brachial plexus (Fig. 3). A particular attention to the transverse cervical vessels, which are left in a more superficial plane is needed. Optic can be inserted through the medial portal and devices through the supracavicular portal. Identification of the upper plexus trunk, and emergence of the suprascapular nerve(Fig. 4) raising laterally and posteriorly towards the coracoid notch is done. At this anatomical location the suprascapular artery can cross the plexus over the upper trunk or between the upper and middle trunk. More inferiorly the dorsal scapular artery can be found at the level of the midle trunk.
Adhesions and/or a thickened fascia can be visualized between the scalene muscles and the brachial plexus. This fascia must be released, allowing visualization of the scalene muscles. Then suprascapular nerve neurolysis can also be performed at this point.
The cervical portal is made about 2.5 cm from the supraclavicular portal. and the radiofrequency device is inserted and used to increase the space around the entry point. Distance parameters may vary, but as usual, the portal is created under
vizualisation control, with the aim to create access between the middle and anterior scalenes. The optics is moved to the supraclavicular portal. The release of the sheath to the scalene hiatus is continued using radiofrequency through the cervical portal(Fig. 5). Regarding the phrenic nerve which course is on the anterior border of the anterior scalene muscle, it is not easy nor necessary to visualize this nerve by endoscopy, however if visualized it needs to be protected. The middle scalene is dissected(Fig. 6) and one can identifies the dorsal scapular nerve and/or the long thoracic nerve. They actually have a very similar origin, but their directions are different, the dorsal scapular nerve goes posteriorly and medially and the long thoracic nerve goes inferiorly, more anterior and above the first rib.
These nerves usually present an intramuscular path, the middle scalene myotomy can be done by direct visualization in order to release them. One can use the nerve stimulator in order to better understand which nerve is going to be released.
Subclavian artery can be visualized after the complete release of the anterior and middle scalenus muscles(Fig. 7)(Film. 1). Portals developed to this technique are as in the Fig. 8.
Thereafter revision of hemostasis and additional scalene myotomies may be performed with radiofrequency. A needle is positioned between the 2 cervical portals for infiltration of a betametasone, tramadol, tranexamic acid and magnesium sulfate solution.
The extubation requires additional care because sometimes infused fluid can compress the airways.
For neuropathic analgesia, drugs are administered according to the patient’s needs, including pregabalin, nortriptyline, vitamin C, prednisone, opioids and anti-inflammatory drugs. Ten days after surgery, the stitches are removed and the patient is able to remove the sling.
Tips and Tricks are in Table. 1, comparison with open surgery in Table. 2.
Endoscopic release of the brachial plexus as suggested in this technical note offers advantages compared to an open technique or to previoulsy described endoscopic techniques. It provides indeed a better visualization of the neurologic structures with magnification thanks to the arthroscope, almost equivalent to a microsope. It allows a three-level release, i.e. supraclavicular, retroclavicular in the costoclavicular outlet, and infraclavicular. It allows multiple level release without multiple approaches as required in case of an open scalenectomy and pectoralis minor tenotomy11, and thus less scar tissue formation since minimally invasive.
Endoscopic techniques have been described before4 however they mainly managed retro clavicular and infra clavicular decompression. The supraclavicular decompression was addressed in those techniques though a different approach starting from the subacromial space, reaching the suprascapular nerve and the interscalenic area, up to the upper trunk, managing a local fibrous band section, and a neurolysis, but lacking two main aspects which are capital to the Thoracic outlet syndrome management: Scalenectomy, and exposition of the middle and inferior trunks. As described in the previous articles4,12 safe approach of the middle and inferior trunks, and correct exposition of the subclavicular artery, phrenic, long thoracic, and dorsal scapular nerves was not achievable. Meanwhile, Garcia et al11, had described in 2012 an anatomical exposition of the previously cited structures, using a different technique and mainly a different surgical strategy. The procedure presented on this technical note has showed an improvement on the clinical scores which was greater than the previously published series4[JCGJ1] . It seems obvious that the release addressed on this technical note is more exhaustive, but the thorough release of the whole brachial plexus affords better clinical results. The main difference and benefit brought by this technique is the ability to perform a scalenectomy. The scalene muscles are clearly identified as compressors in this pathology. Scalenectomy is indeed a mandatory step of the open surgical procedure13.
However, limitations can be raised. The first and most obvious one, is the importance of the learning curve. The interscalenic area is an anatomical region which must be well known before adventuring oneself around it endoscopically. Before performing the scalenectomy, the nerves and vessels around must be identified and preserved. When a doubt regarding the identification of those structures exists, the surgeon should never hesitate to convert to an open approach. It is therefore a technique that must be managed by surgeons trained into brachial plexus and peripheral nerve surgery.
The area is also sensible to pressure variation. Indeed a balance between low blood pressure, and high inflow pressure must be reached. The surgeon needs perfect bleeding management in order to obtain good visualization, and anesthesiologists must manage the blood and water inflow pressure in order to prevent neurological complications. Indeed, compressions can occur to the pneumogastric nerve, the carotid body but also to the spinal chord.
Overall, this technique is clearly bringing many advantages to the management of neurogenic thoracic outlet syndromes, and we recommend that it becomes the reference technique compared to open techniques or previously described endoscopic techniques14. However, we acknowledge that it must be limited to neurogenic cases, and to cases where no anatomical variations or modifications3 is identified. It should not be applied to cases where symptomatic vascular compression occurs, and it is not a technique enabling first rib resection. As a matter of fact, we have not studied yet proved that the results obtained with neurogenic syndromes are applicable to vascular syndromes. At last, anatomical knowledge of the area by the surgeon, and ability to work in the region in open surgery as well as anesthesiology cooperation is mandatory.
Illig K, Donahue D, Duncan A, Freischlag J, Gelabert H, Johansen K, et al. Reporting standards of the society for vascular surgery for thoracic outlet syndrome. J Vasc Surg. 2016;64(3):e23-35.
Levine N, Rigby B. Thoracic outlet syndrome: biomechanical and exercise considerations. Healthcare. 2018; 6(2). piiE68.
Ferrante M, Ferrante N. The thoracic outlet syndromes: part 1. The arterial, venous, neurovascular, and disputed thoracic outlet syndromes. Muscle Nerve. 2017; 55(6):782-93.
Lafosse T, Hanneur M, Lafosse L. All-endoscopic brachial plexus complete neurolysis for idiopathic neurogenic thoracic outlet syndrome: surgical technique. Arthrosc Tech. 2017;6(4):e967-71.
Kuhn J, Lebus G, Bible J. Thoracic outlet syndrome. J Am Acad Orth Surg. 2015; 23(4):222-32.
Doneddu P, Coraci D, De Franco P, Paolasso I, Caliandro P, Padua L. Thoracic outlet syndrome: wide literature for few cases. Status of the art. Neurol Sci. 2016;38(3):383-8.
Chang DC, Rotellini-coltvet LA, Mukherjee D, De Leon R, Freischlag LA. Surgical intervention for thoracic outlet syndrome improves patient’s quality of life. J Vasc Surg. 2009;49(3):630–5
Soukiasian H, Shouhed D, Serna-Gallgos D, Mckenna R, Bairamian B, mckenna r. A video-assisted thoracoscopic approach to transaxillary first rib resection. Innovations (Phila). 2015; 10(1):21-6.
Balderman J, Holzem K, Field B, Bottros M, Abuirqeba A, Vemuri C et al. Associations between clinical diagnostic criteria and pretreatment patient-reported outcomes measures in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome. J Vasc Surg. 2017; 66(2):533-44.e.
Garcia JC, Mantovani G, Livernaux P. Brachial plexus endoscopy: feasibility study on cadavers. Chir Main. 2012; 31(1):7-12.
Lafosse T, Masmejean E, Bihel T, Lafosse L. Brachial plexus endoscopic dissection and correlation with open dissection. Chir Main. 2015; 34(6):286-93.
Cheng SWK, Reilly LM, Nelken NA, Ellis WV, Stoney RJ. Neurogenic thoracic outlet decompression: rationale for sparing the first rib. Cardiovasc Surg. 1995; 3(6):617–23.
14.Ferrante M, Ferrante N. The thoracic outlet syndromes: part 2. The arterial, venous, neurovascular, and disputed thoracic outlet syndromes. Muscle Nerve. 2017; 56(4):663-673.
Fig.1: Scope through the anterioinferior portal: A) Fat over the Brachial Plexus, B) Released Pectoralis minor tendon
Fig. 2 Scope through the anterioinferior portal: A) Subclavius Muscle Released, B:Electrocautery device.
Fig. 3 Scope through the medial portal: A) Upper Trunk, B) Suprascapular artery.
Fig. 4 Scope through the medial portal: A) Suprascapular nerve, B Upper Trunk
Fig. 5 Scope through the supracavicular portal: A) Fribrous adhesion, B) Anterior Scalene Muscle
Fig. 6 Scope through the supracavicular portal: A) Scalene Muscle, B) Brachial Plexus
Fig. 7 Scope through the supracavicular portal: A) Scalen Muscles Released, B) Subclavian Artery, C) Dorsal Scapular Artery.
Fig. 8 Special portals designed for the procedure: A) Anterioinferior, B) Medial, C) Supraclavicular, D) Cervical
Table. 1 Tips and Tricks
Table. 2 Comparisson between Endoscopic and Open procecedures
Endoscopic release of the Brachial plexus is a technical from NAEON Institute Sao Paulo-Brazil and Alps Surgery Institute/Clinique Générale d’Annecy-France.
After the Pectoralis Minor Release, the region of its cords and distal nerves is cleaned.
Dissection between the Pectoralis Minor and conjoined tendon is important and will expose the musculocutaneous nerve.
Here the musculocutaneous nerve is exposed.
Following key structures and the plexus one careful dissects this region until achieve the subclavius muscle’s fascia.
The subclavius muscle’s fascia is opened and the muscle is exposed
All the muscle is released, and the clavicle is reached.
Just after the superior border of the clavicle the supraclavicular portal is made.
In the cervical direction a dissection of structures over the brachial plexus is done and the trunks of the brachial plexus are exposed.
Shaver with no aspiration can also be used.
Suprascapular nerve is visualized at the lateral border of the brachial plexus
Continuing dissection one can expose the suprascapular artery over the upper trunk
Anterior Scalenus muscle and fibrotic bands are reached.
The Anterior Scalenus muscle is carefully released.
The Middle Scalenus muscle have to be also released with special care because the Scapular Dorsal and Thoracic Long Nerves, released in this video were in the middle of this muscle.
Subclavian artery can be visualized, however it is not mandatory.
Online Submissions: http: //www.ghrnet.org/index.php/ijo Int. J. of Orth. 2019 February 28; 6(1): 1012-1015 doi: 10.17554/j.issn.2311-5106.2019.06.281-4 ISSN 2311-5106 (Print), ISSN 2313-1462 (Online)
Principles of the Superior Capsule Reconstruction of the Shoulder
Jose Carlos Garcia Jr., Matheus R. Barcelos, Felipe Machado do Amaral, Mauricio de Paiva Raffaelli, Álvaro Motta Cardoso Jr.
Jose Carlos Garcia Jr., Matheus R. Barcelos, Felipe Machado do Amaral, Mauricio de Paiva Raffaelli, Álvaro Motta Cardoso Jr., NAEON Institute São Paulo- Brazil
Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Com- mons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non- commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Jose Carlos Garcia Jr., NAEON Institute São Paulo, Brazil. Email: email@example.com
Received: September 14, 2018 Revised: November 18, 2018 Accepted: November 20, 2018 Published online: February 28, 2019
Massive rotator cuff tears, involving the posterosuperior rotator cuff, remain difficult to treat particularly in the younger population. Fatty infiltration of the muscle, excessive chronic tendon retraction, and degeneration are the main irreversible factors predisposing to high failure rates of direct repair. There are many techniques for Superior Capsular Reconstruction (SCR) mainly using allograft. However low accessibility to the dermal grafts in many countries led the authors to use and suggest autograft of the fascia lata as other option for the reconstruction of the superior capsule of the shoulder. The SCR have presented good functional and biomechanical results. These tech- niques are reliable options for irreparable lesions of the rotator cuff.
Garcia JC, Barcelos MR, Amaral FM, Raffaelli MP, Cardoso AM. Principles of the Superior Capsule Reconstruction of the Shoulder. International Journal of Orthopaedics 2019; 6(1): 1012-1015 Available from: URL: http://www.ghrnet.org/index.php/ijo/article/ view/2437
Massive rotator cuff tears, involving the posterosuperior rotator cuff, remain difficult to treat particularly in the younger population.
With an arthroscopic, or open approach, rotator cuff repair is pos- sible in the majority of cases and functional outcomes are improved.
The term “irreparable” has been used with different meanings in the past. For example, the term was frequently used when partial re- pair of the rotator cuff was performed.
More recently, a subtle change in meaning was adopted. The term “irreparable” began to be used to describe a rotator cuff that was either (1) predicted to be irreparable based on preoperative characteristics; or (2) predicted to have a poor outcome from rotator cuff surgery, regard- less of the possibility of achieving current intraoperative repair.
Fatty infiltration of the muscle, excessive chronic tendon retraction, and degeneration are the main irreversible factors predisposing to high failure rates of direct repair. Some authors say that the term ir- reparable should only be applied intraoperatively.
Hanada et al first described a “superior capsular reconstruction” of the glenohumeral joint as a revision operation in a paraplegic patient with an irreparable supraspinatus tendon tear[1,3]. During a postopera- tive follow-up, 1.2 years after the surgery, pain persisted as well loss of function. Muscle strength and endurance deteriorated to “fair”. In summary, the overall result was unsatisfactory.
During cadaveric studies of patch graft surgery, for irreparable rota- tor cuff tears, Mihata et al discovered that the graft should be attached
medially to the superior glenoid and laterally to the greater tuberosity in order to restore superior stability of the humeral head.
After clinical studies, Mihata et al reported on the use of fascia lata autograft to arthroscopically reconstruct the superior capsule of twen- ty-four shoulders, in twenty-three patients, all with large, irreparable rotator cuff tears. Reported outcomes of this study were excellent, with significant improvements in pain, function, and range of motion in forward flexion and abduction, beside the increase of the subacro-
 mial space shown in radiography .
While reported outcomes were favorable, it is important to note
this technique increases surgical time and carries donor-site morbid-
ity. Hirahara and Adams subsequently proposed the use of dermal
allograft for Superior Capsular Reconstruction (SCR) as opposed to
[6,7] fascia lata . Dermal allografts limit donor-site morbidity, have been
used previously in augmentation of rotator cuff repairs, and have
 been used clinically for SCR .
Despite growing interest in the use of these techniques with the
 dermal allograft technology, their cost is a potential impediment .
It is important to note that other new techniques, which use the Long Head of the Biceps Tendon (LHBT) as autologous graft, with partial repair of the rotator cuff or side-by-side suture, have also been described by several authors[8-11].
ANATOMY AND BIOMECHANICS
The anatomy of the glenohumeral joint capsule is not uniform for all. The cuff and superior capsule are a mix of blended fibers. Thus, the superior capsule serves to transmit force from the cuff musculature to the bone, and to reinforce tendon insertions. In this manner, the supe- rior capsular complex contributes to active glenohumeral stability.
Anatomical studies have revealed a larger insertional footprint of the superior capsule than had previously been recognized: from 5 to 9 mm in medial–lateral width at the anterior and posterior margins[14,15]. The superior capsule is connected to 30% and 61% of the greater tu- berosity and can have a larger footprint on the greater tuberosity than the supraspinatus. Therefore demonstrating that the superior capsular complex is critical for passive glenohumeral stability.
Indications for Superior Capsule Reconstruction (SCR) surgery, are those patients with irreparable rupture of the rotator cuff, those with pseudoparalysis, those who may have already undergone treatment or not, upper instability that can be observed as ascending humeral head, and/or young patients who are not candidates for reverse shoulder arthroplasty[1,9,16,17]. Patients presenting with evidence of a Hamada IV classification (or greater), advanced arthritic changes, and poor deltoid function are all relative contraindications to this procedure.
Magnetic Resonance Imaging should be consistent with an irreparable rotator cuff tendon tear and demonstrate a retraction greater than 3 cm, along with Grade 3 changes of the supraspinatus or Grade 2 changes
 of the infraspinatus on sagittal oblique imaging . Plain radiographs
also need to be obtained to rule out significant arthritis, confirm supe- rior instability, and superior dislocation of the humeral head.
Rotator cuff strength is assessed initially by testing the resisted ex- ternal rotation (to detect tears of the supraspinatus, infraspinatus, and
teres minor). A positive Hornblower’s Test and Lag Sign indicate involvement of the supraspinatus, infraspinatus, and teres minor. In addition, subscapularis function is tested by means of the Bear Hug, Belly Press, and Lift-Off Tests.
These techniques require an experienced surgeon and surgical team, in addition to the appropriate (sometimes considerable) time needed to complete the procedure. Preparation of the joint, before beginning the reconstruction of the upper capsule, is of the utmost importance.
Acromioplasty can be performed to improve visualization of the subacromial space, but some authors preserve the coracoacromial ligament in massive cuff surgery.
Biceps tenotomy for elder and tenodesis of the biceps for the younger patients can be performed according to the surgeon’s prefer- ence.
Partial cuff repair is almost always possible and should be per- formed routinely to improve the forward range of motion, and avoid possible suprascapular nerve compression.
The subscapularis tendon should be sutured in the minor tubercle, according to the surgeon’s technical preference, as it plays an impor- tant role in the static and dynamic stability of the shoulder. Without a functional subscapularis suture, the reconstruction of the upper cap- sule may fail.
Release of the teres minor and infraspinatus should be done to cov- er as much area as possible during the repair. The posterior interval slide technique is a viable option to improve tendon mobility. Good postero-lateral coverage improves the prognosis of external rotation in the postoperative period, since the upper capsule will be the stabi- lizer that will make the fulcrum of the glenohumeral joint, while the remaining tendons move the joint.
Exposure of the glenoid should be extensive, with removal of all tissue from the supraglenoidal tubercle for easy identification of fu- ture anchor location.
Mihata et al. inserted the anchors into the superior glenoid at the 10 to 11 o’clock and 11 to 12 o’clock positions on the glenoid of the right shoulder (or the 1 to 2 o’clock and 12 to 1 o’clock positions of the left shoulder).
The Nevasier Portal and accessory portals anterior and posterolat- eral should be used when necessary. Angle placement of the anchor is critical, as there must be no invasion of the joint. If the distance be- tween the anchors is greater than 35 mm a third anchor may be used.
The major tuberosity of the humerus is prepared by removing all remaining tissue leaving a propitious and scarified bone area.
A milimetered probe is used to measure the anteroposterior dis- tance to the glenoid, the anteriorposterior distance to the great tuber- cle, and the medial lateral distances. A made-to-measure graft is then fashioned based on these specific measurements.
To provide tissue for fixation, 5 mm is added to the medial, an- terior, and posterior dimensions and 15 mm is added to the lateral dimension, to account for the rotator cuff footprint[17,20].
A vertical skin incision is made, over the lateral thigh and around the greater trochanter of the femur. A section of fascia lata 2 to 3 times the size of the superior capsular defect is harvested, after which a graft 6 to 8 mm thick is fashioned by folding the fascia Lata twice or thrice as necessary (Figures 1 and 2).
The glenoid anchor wires should be arranged on the graft before the latter is transported through the cannula in the lateral portal and guided to its location in the glenoid. There are successful several variations of this strategy, which depend on the choice of glenoid an-
Garcia JC et al. Principles of the Superior Capsule Reconstruction of the Shoulder
Garcia JC et al. Principles of the Superior Capsule Reconstruction of the Shoulder
Figure 1 Fascia Latagraft.
Figure 2 Fascia Lata preparation for superior capsular reconstruction.
chor and the size of the graft. Insertion of the graft into the joint is the most challenging part of
the procedure (Figure 3). Several technical tips can help to prevent complications.
The sutures in the medial row of the greater tuberosity are crossed over the graft and secured with 2 additional lateral suture anchors in a transosseous-equivalent style repair (Figure 4). This is done with 20° to 30° of arm abduction.1 Mihata, however, in his original paper references the use of 45° of abduction.
The important concept to note is that, the graft should not be placed with laxity.
The graft is then sutured to the infraspinatus using 2 or 3 sutures in a simple fashion. This a not an optional step[1,6,21].
Reconstruction of the upper capsule using the LHBT, consists of preserving the previously integrated bicipital insertion, evaluating the viability of the remaining LHBT with no excessive tendinitis or par- tial tears.
Repairable partial and/or full infraspinatus and subscapularis ten-
Figure 3 Insertion of the Graft.
Figure 4 Capsular Superior Reconstruction scheme. (created by Dr Felipe do Amaral one of the authors).
don tears must be reconstructed to ensure the stabilizing force couple in the transverse plane.
A 5.5 mm suture anchor is inserted approximately in the middle of the greater tuberosity (just behind the bicipital groove). The surgeon then passes all sutures through the intact LHBT, performing a “lasso- loop” configuration. (Figure 5).
After this, tenotomy with or without tenodesis is performed on the biceps distal to the suture. Sutures are then pulled and tied by placing the tendon in the desired position.
Side-to-side fixation of the infraspinatus and subscapularis with the LHBT is performed.
Postoperative radiographs should show down-migration of the hu- meral head after procedure.
The use of an abduction pillow, for 4 weeks after the reconstruction surgery, is recommended. After the immobilization period, passive and active-assisted exercises were initiated.
Eight weeks after surgery, patients begin to perform exercises in order to strengthen the rotator cuff and scapula stabilizers with the as-
sistance of physical therapists. Active overhead motion strengthening exercises are not advised
in the period up to four months after surgery. Thus allowing adequate time for allograft incorporation and cuff healing. High-demand ac- tivities are restricted for 1 year after surgery.
Hirahara et al use musculoskeletal ultrasound to evaluate the dermal allograft. Subsequently showing that the graft is incorporated into the patient’s body and transformed into host tissue. Vasculariza- tion was found using a Doppler 4-8 months after surgery, thus prov- ing incorporation of the tissue.
The SCR technique has shown very good functional and biomechani- cal results. In the body of this article, several technical options are described using either a Dermal graft or less expensive alternatives such as fascia lata and LHB. As surgeons become more familiar with the SCR technique, the use of this surgery, as an option for irrepa- rable lesions of the rotator cuff, will significantly increase.
Ek ET, Neukom L, Catanzaro S, Gerber C. Reverse total shoul- der arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen years. J Shoulder Elbow Surg. 2013; 22(9): 1199-1208. [PMID: 23385083]; [DOI: 10.1016/j.jse.2012.11.016]
Hanada K, Fukuda H, Hamada K, Nakajima T. Rotator cuff tears in the patient with paraplegia. J Shoulder Elbow Surg. 1993; 2(2): 64- 69. [PMID: 22971671]; [DOI: 10.1016/1058-2746(93)90002-X]
Mihata T, McGarry M, Pirolo J, Lee M. Superior Capsule Reconstruction to Restore Superior Stability in Irreparable Rotator Cuff Tears: A Biomechanical Cadaveric Study. Am J Sports Med 2012; 40(10): 2248-55. [PMID: 22886689]; [DOI: 10.1177/0363546512456195]
Mihata T, Lee TQ, Watanabe C, et al. Clinical results of ar- throscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy 2013; 29(3): 459-70. [PMID: 23369443]; [DOI: 10.1016/j.arthro.2012.10.022]
Hirahara AM, Adams CR. Arthroscopic superior capsular recon- struction for treatment of massive irreparable rotator cuff tears. Arthrosc Tech 2015; 4(6): e637-e641. [PMID: 26870638]; [DOI: 10.1016/j.eats.2015.07.006]
Denard PJ, Brady PC, Adams CR, Tokish JM, Burkhart SS. Pre- liminary Results of Arthroscopic Superior Capsule Reconstruction with Dermal Allograft. Arthroscopy. 2018; 34(1): 93-99. [PMID: 29146165]; [DOI: 10.1016/j.arthro.2017.08.265]
Boutsiadis A, Chen S, Jiang C, Lenoir H, Delsol P, and Barth J. Long Head of the Biceps as a Suitable Available Local Tis- sue Autograft for Superior Capsular Reconstruction: “The Chi- nese Way”. Arthroscopy Techniques 2017; 6(5): e1559-e1566.
Hermanowicz K, Góralczyk A, Malinowski K, Jancewicz P,Domzalski M. Long Head Biceps Tendon Natural Patch for Mas- sive Irreparable Rotator Cuff Tears. Arthroscopy Techniques, 2018; 7(5): e473-e478. [PMID: 29868421]; [DOI: 10.1016/ j.eats.2017.11.008]
Chillemi C, Mantovani M, Gigante A. Superior capsular recon- struction of the shoulder: the ABC (Arthroscopic Biceps Chillemi) technique. European Journal of Orthopaedic Surgery & Trau- matology. 2018; 28(6): 1215-1223. [PMID: 29564612]; [DOI: 10.1007/s00590-018-2183-1.
Kim YS, Lee HJ, Park I, Sung GY, Kim DJ, Kim JH. Arthroscopic In Situ Superior Capsular Reconstruction Using the Long Head of the Biceps Tendon. Arthrosc Tech. 2018; 7(2): e97-e103. [PMID: 29354447]; [DOI: 10.1016/j.eats.2017.05.020]
Adams CR, DeMartino AM, Rego G, Denard PJ, Burkhart SS. The Rotator Cuff and the Superior Capsule: Why We Need Both. Arthroscopy. 2016; 32(12): 2628-2637. [PMID: 27916191]; [DOI: 10.1016/j.arthro.2016.08.011]
Clark JM, Harryman DT II. Tendons, ligaments, and capsule of the rotator cuff: gross and microscopic anatomy. J Bone Joint Surg Am. 1992; 74(5): 713-725. [PMID: 1624486]
Nimura A, Kato A, Yamaguchi K, et al. The superior capsule of the shoulder joint complements the insertion of the rotator cuff. J Shoulder Elbow Surg. 2012; 21(7): 867-872. [PMID: 21816631]; [DOI: 10.1016/j.jse.2011.04.034]
Ishihara Y, Mihata T, Tomboli M, et al. Role of the superior shou- lder capsule in passive stability of the glenohumeral joint. J Shou- lder Elbow Surg. 2014; 23(5): 642-8. [PMID: 24388150]; [DOI: 10.1016/j.jse.2013.09.025]
Sethi P, Franco G. The Role of Superior Capsule Reconstruction in Rotator Cuff Tears. Orthop Clin North Am. 2018; 49(1): 93- 101. [PMID: 24388150]; [DOI: 10.1016/j.jse.2013.09.025]
Yoo JC, Ahn JH, Yang JH, Koh KH, Choi SH, Yoon YC. Cor- relation of arthroscopic repairability of large to massive rota- tor cuff tears with preoperative magnetic resonance imaging scans. Arthroscopy 2009; 25(6): 573-82. [PMID: 19501285]; [DOI: 10.1016/j.arthro.2008.12.015]
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Garcia JC et al. Principles of the Superior Capsule Reconstruction of the Shoulder
Robotic surgery has been used for a long time, it is earning space and expanding of use to daily medical practice in several surgical specialties with advantages over the traditional surgical methods. This technical Note presents an endoscopic robotic posterior shoulder approach that allow the surgeon to perform Latissimus Dorsi transfer endoscopically.
This technical note aims to present the using of the DaVinci®(Intuitive Surgical, Sunnyvale, CA, USA) robot for transfers related to rotator cuff tears.
Robotic surgery has been used for a long time1-2, it is earning space and expanding of use to daily medical practice in several surgical specialties with advantages over the traditional surgical methods3,4. Within orthopedics, we highlight the use of robotics in brachial plexus6,7 and neurologic releases7-9.
The association of the robotic technology with endoscopy have further allowed a faster recovery for the patient for many applications with shorter time of hospitalization and minimally invasive approache10.
Advantages of this method include movement accuracy, high resolution imaging with three-dimensional vision, gas infusion rather than saline solution (better visualization), filtering of the surgeon’s tremor when manipulating objects, movement scaling and hand-free camera manipulation11-14. In addition for future, there is the possibility of remote surgery (telesurgery) where the surgical team can treat a patient far away1, 2 or a surgical team may be composed of professionals located in different cities or countries, treating the same patient simultaneously.
Some shoulder pathologies that will need posterior shoulder approach may need aggressive and traumatic exposure with extensive manipulation of soft tissues. The possibility to use a minimal invasive approach can potentially be important for both the time of rehabilitation and avoiding local soft tissue adhesions. In Addition, when performing a large posterior open approach, one needs the use of tensioned retractors in order to keep the surgeon’s field in a suitable manner. The use of these tensioned retractors can eventually damage the deeper muscle layer as well as other neurovascular structures15,16.
The minimally invasive procedures have demonstrated decrease of adhesions, avoiding reoperations and physical therapies during long times. Indeed, this advantage mentioned above make these procedures cost-effectives10.
There are few descriptions using the aid of robotics in the area of orthopedics, especially in shoulder surgery, a practice already widespread in other surgical areas, but which have been gaining space and recent publications17-19.
In shoulder surgery, the use of robotic-assisted surgery for better identification of the quadrangular space of the shoulder, identification of the axillary and radial nerves, and better identification of the latissimus dorsi muscle was done in a cadaver trial before20.
The visualization and partial manipulation of the latissimus dorsi muscle has already been reported, in order to aid the transportation of the muscular pedicle, with technique that was used as reference for our study19.
Axillary nerve identification has also been described9, making a contribution to our study and confirming the viability of the method.
Regarding bleeding, studies in live patients have shown that the air insufflation have been effective on avoiding it8.
This technical note is based on previous cadaveric trials20 and aims to present the using of the DaVinci®(Intuitive Surgical, Sunnyvale, CA, USA) robot for transfers of the latissimus dorsi tendon to humeral head we have already performed in four live patients for massive rotator cuff tears.
Indications, pre-operative evaluation and imaging
This procedure has the same indications of the traditional open transfer of the Latissimus dorsi tendon, patients with massive rotator cuff tears with poor biologic characteristics of the tendon. Fat infiltration degrees 3 and 4 of Goutallier with a retraction of more than 4cm in patients under 60 years presenting active subscapularis tendon is the ideal surgical indication.
Patients will present pain and difficulty or impossibility for shoulder elevation and abduction. The youngest the patient is, better tends to be the result.
Patient is left in ventral decubitus, the arm being maintained in a position similar to 90o elevation.
The inferior border of the Latissimus Dorsi can be localized by palpation. A draw of the muscle is done in the skin based on its inferior border and its known anatomy. A central line of the Latissimus Dorsi is also drawn. An 1cm incision is made in the skin, 10 to 15cm from the axilla, the central portal. Two other portals are made 5-7cm perpendicular medial and lateral to the central line. These portals are located 7-10cm from the axilla. The central portal is used to insert the optics and through the other two portals the robotic hands were introduced to access the muscular fascia where a cavity was formed through blunt dissection.This space was made for triangulation as an initial working cavity, once there are no natural cavities in this region.
A trocar and a canula are introduced into each of the incisions, in a common direction in the cavity the surgeon created (Fig. 1). In the first portal on the trapezius, the camera of the DaVinci® SI or Xi robot (Intuitive Surgical, Sunnyvale, CA, USA), with an optic of 300(Fig.2) is introduced.
Carbon dioxide was inflated at a constant 8-14mmHg pressure through the chamber portal into the working cavity, stretching the soft tissues and opening the cavity. The robotic arms used a Cadieri Forceps 8mm (Intuitive Surgical, Sunnyvale, CA, USA) and a Hot ShearsTM Monopolar Curved Scissor 8mm (Intuitive Surgical, Sunnyvale, CA, USA).
The first objective was to clean the area around the camera so that a best dissection and identification of the initial working cavity is done. After this first stage, we search for the superior border of the latissimus dorsi muscle and its division with teres major. Dissection using this muscular plane is done until its entrance deep into the medial border of the long head of the triceps(Fig. 3).
The Latissimus is released and separated from the teres major(Fig. 4), the radial nerve is just below the latissimus and it is possible to visualize it but not required (Fig. 5). One needs to take care the neurovascular pedicle in order to not damage it. A 0 Vicryl™ J318(Johnson & Johnson-São Paulo-Brazil) is inserted by the cephalic robotic hand’s portal. The latissimus dorsi tendon is sutured by using a Cadieri and a DeBakey Forceps(Intuitive Surgical, Sunnyvale, CA, USA)(Fig. 6)(Video. 1). The sutured tendon is pulled out of the body through the central portal of the optics using a gastric forceps.
A small 3-5cm incision is done on the lateral deltoid and using the finger a dissection of the subdeltoid space reaches the cavity created by the robot. A long gastric grasper is inserted through the cephalic robotic hand’s portal until it reaches the subdeltoid space. A guide polyester 5.0 wire is passed by using this grasper, leaving optics portal(Fig. 7).
The humeral head is drilled and 2 anchors are inserted. These anchor wires will pass from the deltoid approach to the optics portal using the 5.0 polyester wire as a guide.
The tendon is sutured to the anchor wires using a Krakow(Fig. 8) and passes to subacromial space pulled by the anchor wires, and a standard tendon to bone suture is done. More anchors and sutures can be done after the tendon lies the humeral head.
Portals and deltoid lateral approach are sutured.
A sling is used for 5 weeks. Pendular movements and passive elevation until 90º are allowed 2 weeks after surgery. After this period the active exercises isometric external rotation and elevation begin. In more two weeks isokinetic and proprioception movements begin. A scapular retraction and shoulder extension need to be stimulated in the initial movements, once Latissimus dorsi can also be activated during these movements. Better evolutions are present in patients with better active movements before the surgery.
Pearls and pitfalls are summarized on table. 1. Advantages and Disadvantages are summarized on table. 2.
Traditional approaches for the latissimus dorsi are wide requiring big posterior incisions with cosmetic and scar formation implications.
Previous cadaveric and live patient studies were used to stablish principles for the robotic latissimus dorsi transfer presented on this technical note.
The authors aim to present a surgical technique that can be improved and even be used for other orthopedic applications with future introduction new robots, new robotic arms and smaller optics.
There are few studies assessing the latissimus dorsi using the aid of robotics, all of them access the muscle and the origin of the latissimus for free flaps17-20. This is the first in vivo robotic assisted shoulder surgical procedure done for transfer of the latissimus dorsi insertion to improve function after rotator cuff tears. Tendon, neurovascular structures, quadrangular space were robotically identified in cadaver trials by the author before in other trials, thus surgical viability and safety of the procedure were previously checked9,20.
Other robotic orthopedic applications in live patients have also demonstrated that the air insufflation effectiveness on better bleeding conctrol8.
The viability of the robotic introduction in shoulder surgery was shown by the authors that hope to encourage further studies in the area.
The limitations of this technique are cost of the robot, robotic hands and its scisures. Necessity of specific training on robotic surgery, that is currently costly and not available in many hospitals, can also limits its current use.
In this moment surgical time is longer than in the open procedure, however this situation tends to improve on time.
1. Ballantyne GH, Moll F. The da Vinci telerobotic surgical system: the virtual operative field and telepresence surgery. Surg Clin North Am. 2003; 83:1293-304.
3. Oldani A, Bellora P, Monni, M, Amato B, Gentilli S. Colorectal surgery in elderly patients: our experience with DaVinci Xi® System. Aging Clin Exp Res. 2017; 29(1):91-99.
4. Gallotta V, Cicero C, Conte C, Vizzielli G, Petrillo M, Fagotti A et al. Robotic Versus Laparoscopic Staging for Early Ovarian Cancer: A Case Matched Control Study. J Minim Invasive Gynecol. 2017; 24(2):293-298.
5. Mantovani G, Liverneaux PA, Garcia JC, Berner SH, Bednar MS and Mohr CJ. Endoscopic exploration and repair of brachial plexus with telerobotic manipulation: a cadaver trial. J Neurosurg. 2011;115(3):659-64.
6. Garcia JC, Lebailly F, Mantovani G, Mendonça LA, Garcia JM and Liverneaux PA. Telerobotic Manipulation of the Brachial Plexus. J reconstr Microsurg 2012; 28(7):491-494
7. Garcia JC, Mantovani G, Gouzou S and Liverneaux P. Telerobotic anterior translocation of the ulnar nerve. Journal of Robotic Surgery. 2011; 5(2):153–156.
8. Garcia JC, Montero EFS. Endoscopic Robotic Decompression of the Ulnar Nerve at the Elbow. Arthroscopy Techniques. 2014; 3: 383-387
9. Melo PMP, Garcia JC, Montero EFS, Atik T, Robert EG, Facca S et al. Feasibility of an endoscopic approach to the axillary nerve and the nerve to the long head of the triceps brachii with the help of the Da Vinci Robot. Chirurgie de la Main. 2013; 32: 206-9
10. Morgan JA, Thornton BA, Peacock JC, Hollingsworth KW, Smith CR, Oz MC, Argenziano M. Does robotic technology make minimally invasive cardiac surgery too expensive? A hospital cost analysis of robotic and conventional techniques. J Card Surg. 2005; 20(3):246-51.
11. Byrn JC, Schluender S, Divino CM, Conrad J,Gurland B, Shlasko E, et al. Three-dimensional imaging improves surgical performance for both novice and experienced operators using the da Vinci Robot System. Am J Surg. 2007; 193:519–22.
12. Solis M. New Frontiers in Robotic Surgery: The latest high-tech surgical tools allow for superhuman sensing and more. IEEE Pulse. 2016; 7(6): 51-55.
13. Willems JIP, Shin AM, Shin DM, Bishop AT, Shin AY. A Comparison of Robotically Assisted Microsurgery versus Manual Microsurgery in Challenging Situations. Plast Reconstr Surg. 2016; 137(4): 1317-24.
14. Shademan A, Decker RS, Opfermann JD, Leonard SK, Axel K, Peter CW. Supervised autonomous robotic soft tissue surgery. Sci Transl Med. 2016; 8(337): 337ra64.
15. Wijdicks CA, Armitage BM, Anavian J, Schroder LK, Cole PA. Vulnerable neurovasculature with a posterior approach to the scapula. Clin Orthop Relat Res. 2009; 467(8): 2011-7.
16. Chalmers, Peter Nissen; Van Thiel, Geoff S; Trenhaile, Scott W. Surgical Exposures of the Shoulder. J Am Acad Orthop Surg. 2016; 24(4): 250-8.
17. Selber JC, Baumann DP, Holsinger FC. Robotic latissimus dorsi muscle harvest: a case series. Plast Reconstr Surg. 2012; 129(6):1305-12.
18. JH Chung, You HJ, Kim HS, Lee BI, Park SH , Yoon ES. A Novel Technique for Robot Assisted Latissimus Dorsi Flap Harvest. J Plast Reconstr Aesthet Surg. 2015; 68 (7), 966-72.
19. Ichihara S, Bodin F, Pedersen JC, Melo PP, Garcia JC, Sybille F et al. Robotically assisted harvest of the latissimus dorsi muscle: A cadaver feasibility study and clinical test case. Hand Surgery and Rehabilitation. 2016; 35:81–84
20. Garcia JC, Gomes RVF, Kozonara ME, Steffen AM. Posterior Endoscopy of the Shoulder with the aid of the Da Vinci SI robot – a Cadaveric Feasibility Study. Acta of Shoulder and Elbow Surgery. 2017; 2(1):36-39.
Robotic transfer of the Latissimus Dorsi Tendon from NAEON Institute Sao Paulo Brazil
Portals are done 10-15cm from the latissimus dorsi insertion, 1 central; 1 superior and 1 inferior.
As no natural cavities are present in this area one can gently create a subcutaneous cavity.
The optics trocart is the central, superior and inferior are dedicated to the robotic hands.
This is an external view of the initial subcutaneous and muscular dissection
This is how the surgical site is presented by the robot, but in 3 dimensions.
After a wide dissection the teres major on the left is separated from the latissimus dorsi on the right
The tendon is cut from its humeral insertion
Latissimus is mobilized and separated from the teres major
Care must be taken because as you can see the radial nerve lies just under the tendon
Knowing where the nerve it is easier to release the muscular part or the Latissimus dorsi
The released tendon is sutured
The needle and the wire pass through the optics portal
The deltoid approach is done and a guide polyester wire is also inserted from subdeltoid to the optics portal
Anchors are inserted in the humeral head through the same deltoid approach and their wires are passed by using the guide polyester to the optics portal.
The wires of the suture anchors are sutured on the tendon and the tendon is pulled through cavity until the subdeltoid space and the final fixation in the bone is done
Fig. 1. Patient in ventral decubitus: A and B: Robotic hand trocaters, C: Optics Trocater, D: Shoulder, E: Robotic Exterior Hand, F: Robotic Exterior Hand for Optics.
Fig. 2. Robotic Optics 30º with 2 cameras allowing a stereoscopic view.
Fig. 3. Optics within the central portal. TM:Teres Major, LD: Latissimus Dorsi
Fig. 4. Optics within the central portal. TM: Teres Major, LD: Latissimus Dorsi released
Fig. 5. Optics within the central portal. A: Radial Nerve, B: Teres Major insertion, C: Latissimus Dorsi retracted.
Fig. 6. Optics within the central portal.TLH: Trices Long Head, LD: Latissimus Dorsi, TM: Teres Major
Fig. 7. Patient in ventral decubitus, shoulder and scapular area exposed A: Polyester guide wire through the deltoid approach, B: Gastric forceps, C: Wires where the Latissimus Dorsi was sutured, D: Polyester guide wire exit
Fig. 8. Patient in ventral decubitus, shoulder and scapular area exposed A: Latissimus dorsi sutured with the suture anchor wires, B: The other parts of the suture anchor wires, these will pull the tendon to the humeral head.
Table. 1 Pearls and Pitfalls
Table. 2 Advantages and disadvantages comparing Robotic versus Arthroscopic versus Open surgeries for Latissimus Dorsi transfer.
Massive rotator cuff tears involving the posterosuperior rotator cuff remain difficult to treat, particularly in the younger population. Fatty infiltration of the muscle, excessive chronic tendon retraction, and degeneration are the main irreversible factors predisposing to high failure rates of direct repair. Many techniques exist for superior capsular reconstruction (SCR), mainly using allograft. However, the higher costs of dermal grafts and morbidity of fascia lata autograft led us to find another option for SCR of the shoulder using the semitendinosus autograft as a pivot in a better biomechanical configuration. The pivot SCR technique has shown good functional and biomechanical results. We have found this technique to be a reliable and less expensive option for irreparable lesions of the rotator cuff.
Massive rotator cuff tears involving the posterosuperior rotator cuff remain difficult to treat, particularly in the younger population. The term “irreparable” has been used with different meanings in the past. For example, the term was frequently used when partial repair of the rotator cuff was performed.1 More recently, a subtle change in meaning was adopted. The term “irreparable” began to be used to describe a rotator cuff that was either predicted to be irreparable based on preoperative characteristics or predicted to have a poor outcome after rotator cuff surgery, regardless of the possibility of achieving current intraoperative repair.2 Fatty infiltration of the muscle, excessive chronic tendon retraction, and degeneration are the main irreversible factors predisposing to high failure rates of direct repair. Some authors have stated that the term “irreparable” should only be applied intraoperatively.1
Superior capsular reconstruction (SCR) was described as a revision operation in a paraplegic patient with an irreparable supraspinatus tendon tear.1,3 During cadaveric studies of patch graft surgery for irreparable rotator cuff tears, one group of authors realized that the graft should be attached medially to the superior glenoid and laterally to the greater tuberosity to improve superior stability of the humeral head in SCR.4 This modification resulted in significant improvements in pain, function, and range of motion in forward flexion and abduction, besides the increase in the subacromial space on the roentgenograms.5 Although reported outcomes were favorable, it is important to note that this technique increases surgical time and carries donor-site morbidity.
Other authors proposed the use of dermal allograft for SCR as opposed to fascia lata.6,7 However, surgical costs remained complex to manage for this procedure, creating a gap for other surgical options.8, 9, 10, 11 This Technical Note aims to present a less expensive technique that uses the semitendinosus graft as a central pivot in a better dynamic configuration for SCR (Video 1).
The patient is placed in the beach-chair position under general anesthesia. The semitendinosus tendon is extracted as standardized for anterior cruciate ligament (ACL) reconstruction. The tendon is tensioned and overlapped once in a double-band configuration. Suturing on the final portions of the overlapped graft is performed with No. 5 multifilament polyester suture. This multifilament polyester suture is inserted in a perforated Kirschner wire as used in ACL reconstruction.
The scope is inserted in the posterior portal; an extensive bursectomy is performed, and the lesion can be visualized. The scope is then placed in the lateral portal. Extensive exposure of the scapular neck is performed using a shaver and electrocautery device, with removal of tissue inferior to the supraglenoid tubercle anterior and posterior, to enable easy identification of the bone of the scapular neck, where the graft will pass from posterior to anterior. The labrum is kept intact.
An 18-gauge needle is used to establish the posteromedial portal, which faces the scapular neck just under the glenoid tuberosity. A guide K-wire is inserted through the posteromedial portal and crosses from the posterior (at the 10-o’clock position in the glenoid) to anterior (at the 2- to 3-o’clock position in the glenoid) glenoid neck (Fig 1). A drill the same size as the overlapped semitendinosus tendon is used to create a hole (Fig 2). The perforated K-wire is used to pass the No. 5.0 multifilament polyester suture in 1 final portion of the overlapped graft. Two marks measuring 2 cm are made on each side of the graft to ensure a minimal length on each side. The 2 marks should be visualized by the scope after graft passage. The multifilament polyester suture is pulled through the anterior portal, and the tendon is passed from the posterior to anterior glenoid neck through this hole (Fig 3). With the aid of an atraumatic clamp, both graft legs are placed within the joint, anteriorly in the subcoracoid space and posteriorly in the supraspinatus fossa, exposing the graft terminal fixation and No. 5.0 multifilament polyester suture.
A Neviaser portal is made, and a guide K-wire is inserted approximately 1 cm from the medial border of the greater tuberosity on the humeral head until it crosses the lateral humeral cortex; the arm can be abducted to achieve the best position (Fig 4). A drill that is 1 size higher than the double-overlapped tendon’s size is inserted until it touches the contralateral humeral cortex, not crossing it (Fig 5). The anterior and posterior overlapped graft portions are pulled out of the body through the Neviaser portal. The No. 5.0 multifilament polyester suture in the tips of the graft is inserted in the perforated K-wire and is used to pass the graft through the hole in the humeral head (Fig 6). Tensioning of the tendons is performed similarly to that in ACL reconstruction, and fixation is performed with a metallic interference screw (Hexagon, Itapira, Brazil) (Fig 7). The size of the screw is the same as that of the hole.
If the surgeon prefers stronger fixation, an EndoButton (Razek, São Carlos, Brazil) can be inserted through the humeral head hole before graft insertion and can be used to pass and fix the graft. A release of the teres minor and infraspinatus should be performed to cover as much area as possible during the repair. The greater tuberosity is free for partial cuff repair or any tendon transfer. Repairable partial and/or full infraspinatus and subscapularis tendon tears must be reconstructed to ensure the restoration of the stabilizing forces in the transverse plane.8
Postoperative radiographs will be useful to see the screw and subacromial space (Fig 8). Without a functional subscapularis or its suture, the reconstruction may fail. Accessory portals—anterior and posterolateral—should be used when necessary. Pearls and pitfalls of our technique are summarized in Table 1. Advantages and disadvantages are summarized in Table 2.
Table 1. Pearls and Pitfalls
Pearls and Pitfalls
The graft needs to be large enough to suitably pass through the scapular neck and allow fixation on the humeral head.
Scapular neck perforation
This is the most important step of the described technique. A minimal distance of 7-8 mm is required to avoid articular damage and fracture.
Cleaning of space
Suitable cleaning of the shoulder is needed to allow appropriate visualization of the entire articulation, as well as the scapular neck. Cleaning of the anterior exit point area needs to be highlighted to confirm its correct location and to preserve the subscapularis.
The location is 1 cm from the footprint, within the cartilage of the humeral head nearest the central line perpendicular to the middle of the footprint.
The direction of the perforation needs to be as anterior or anterolateral as possible to avoid the neurologic structures of the arm.
Table 2. Advantages and Disadvantages Comparing Pivot SCR and Traditional SCR
Semitendinosus: autograft or allograft
Fascia lata: autograft or allograft, dermal allograft, or xenograft
1 interference screw
5-7 suture anchors
Graft stress in internal and/or external rotation
Possible association with transfers
Preserves humeral footprint to insert transferred tendons
Does not preserve humeral footprint to insert transferred tendons
NOTE. + = low; ++ = medium; +++ = high.
SCR, superior capsular reconstruction.
We recommend the use of an abduction pillow for 4 weeks after reconstruction surgery. After the immobilization period, passive and active-assisted exercises begin. Eight weeks after surgery, patients can start rotator cuff and scapular stabilization exercises. More than 10 patients have undergone the described procedure, and their results were better than those of traditional SCR in our hands.
Despite growing interest in the use of SCR using dermal allograft technology, its cost is a potential impediment.8 It is important to note that other techniques using the long head of the biceps tendon as autologous graft, with partial repair of the rotator cuff or side-by-side suturing, have been described and cited by several authors as options over traditional SCR.8, 9, 10, 11, 12 We suggest that our surgical procedure using the semitendinosus tendon is easier and presents low costs and good outcomes. This double-overlapped graft measures at least 8 mm in diameter, which is the diameter related to the best results after ACL reconstruction.13,14
Reconstructions of other articulations use the graft insertion as close as possible to the rotational center in the least restrictive manner possible. In our technique, the surgeon inserts the semitendinosus graft in a single pivot configuration nearer the rotational center of the humerus, considering its axial plane. Regarding fixation, double fixation using an EndoButton and interference screw seems to ensure strength enough to stabilize the system until the entire healing process is complete.
A scapular neck fracture is possible; however, in our experience, this will not occur if the exit hole is located at a safe distance from the glenoid. A humeral head fracture is also a hypothetical possibility. Finally, one important consideration is that the exit point needs to be at the 2- to 3-o’clock position; an inferior exit point can put the brachial plexus at risk.
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Video 1. After bursectomy, the scapular neck is exposed by use of the lateral portal (visualization is performed with optics in the lateral portal, and exposure is performed with electrocautery and a soft-tissue shaver). The region medial to the 10-o’clock position in the glenoid needs to be exposed until the bone is visible (with the scope through the lateral portal). A K-wire is inserted in this region and leaves the bone at the 2- to 3-o’clock position. If the surgeon considers the amount of bone sufficient, he or she can drill the scapular neck. The size of the drill is the same as that of the double-overlapped graft. A perforated K-wire inserts the polyester wires of the graft through the scapular neck, similarly to anterior cruciate ligament reconstruction. The polyester is pulled out through the anterior portal, and the graft passes from posterior to anterior through the bone tunnel. The final portions of the graft are pulled out of the bone through the Neviaser portal. Through this portal, a guide K-wire and a drill are inserted 1 cm medial to the tuberosity, in the humeral head cartilage. The size of the drill is the same as that of the double-overlapped semitendinosus graft. A perforated K-wire inserts the guide polyester suture through this hole in the humeral head. The anterior and posterior parts of the graft are inserted within the humeral head. An interference screw presenting the same diameter as the hole is inserted, and the reconstruction is completed.Download : Download Acrobat PDF file (2MB)