Name: Arthrex 3-Point Shoulder Distraction System & S.T.a.R.™ Sleeve
Uploaded: 2000-05-17T00:00:00Z
Channel: Arthrex

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VCD-1041 | A | Arthrex 3-Point Shoulder Distraction System & S.T.a.R.™ Sleeve

Stephen J. Snyder

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A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

Eine Videoaufnahme einer Operationsanleitung an einem lebenden Patienten oder Patientin in einem Operationssaal oder eine Demonstration an einem Humanpräparat.

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Arthrex 3-Point Shoulder Distraction System & S.T.a.R.™ Sleeve

Arthrex presents the techniques for using the Arthrex three point shoulder distraction system and star sleeve. Recommendations and demonstrations are given by Doctor Stephen J. Snyder at the Southern California Orthopedic Institute in Van Nuys, California. The techniques for performing arthroscopic shoulder procedures efficiently are highly dependent on how the surgeon manages the position and distraction of the upper extremity. Recent changes to the Arthrex shoulder distraction system and star sleeve have given the shoulder arthroscopies the ability to position the shoulder quickly and efficiently. The three point shoulder distraction system and star sleeve is designed to supply distal traction, along with abduction angle adjustability, while at the same time supplying humeral rotation and the capacity to quickly adjust and maintain that rotation without the help of an assistant. So we have the normal traction for arthroscopy which is fixed. We have the two point traction which is the lateral strap. And we have the third point which is the traveling pulley. That gives us infinite adjustability. There's a lot of benefits to the system. It's a system that can be used by any shoulder arthroscopy, as he or she gets more and more comfortable and sophisticated in their reconstructions, they can fine tune the position of the arm, adding a little bit of traction, adding a little bit of counter traction, rotating the arm. And it's like everything you do. I guess as you get more and more advanced, then you demand more and more of your apparatus. You can have the best scope in the world, but if you can't position the arm in in the optimal position to do your operation, you can't do the type of surgery that that you want to do. At the beginning of the case, the Arthrex three point shoulder distraction system is placed at the foot of the bed, which will be on the anterior side of the patient, which is on the opposite side of the table. As the shoulder being worked on, the base of the assembly is slid onto the standard Clark rails of the O.R. table from the foot of the bed, or placed over the access tabs on the underside of the rail and positioned. The two black knobs are then tightened down. Once the patient is positioned, the upper boom of the three point traction system is properly extended and rotated so that the end pulley at the red cable end is positioned directly over the head of the humerus. The rotational control is released and locked down by loosening and tightening the black knobs at the base of the device. This positioning is especially important for procedures where lateral humeral traction and rotational control of the humerus is desired. The pulley is extended by releasing the black knob at the top end of the upper boom for routine shoulder arthroscopy and procedures that do not require lateral and rotational control of the humerus. Only the traveling pulley and the lower traction boom needs adjustment. The traveling pulley is attached to the white cable, and is adjusted in the same manner as the upper boom, by lifting the black knob and positioning the pulley for the proper abduction. Then the lower traction, which is the yellow cable traction, is adjusted for the appropriate cited shoulder being worked on for 10 to 15 degrees of forward flexion. Both the lower boom adjustment, as well as rotating the traveling pulley, are performed to accomplish a slight forward flexion. The lower traction is set so that the weights hang anterior to the patient, changing the distraction in the middle of the procedure from 70 degrees of abduction, for example, to 15 degrees of abduction, is simply a matter of instructing the circulator to change the weights from the white colored cable to the yellow. Once the three point shoulder distraction system is properly positioned for the anticipated procedure, the patient is prepped in a routine manner. The Arthrex Star Sleeve is a sterile soft foam device packaged, sterile, specifically designed for use with the three point shoulder distraction system, and provides non-adhesive rotational control of the upper extremity during all routine shoulder arthroscopy. After applying sterile drapes, the star sleeve is first measured to the patient's arm length. If the patient has a short arm, the excess foam can be trimmed from the sleeve end so that the sleeve will not interfere with the operative site. I actually put the star sleeve on myself. My assistant will hold the arm up, and we put the heel of the hand in, facing the floor, with the thumb facing the opening in the star sleeve. That way, the superficial branch of the branch of the radial nerve is always the uppermost, and we can take two folds of the star sleeve. Fold one over the nerve and one over the top of that, and we take the wrist strap and and cinch it around fairly snugly. Since those straps are so wide, they put very little pressure then on that delicate structure. Plus with the arm in that position, then that's again always the reference position. If you always do it that way, you know that when the arms held up it will be in neutral position. So that's important. And then the upper strap I don't put very tight because I don't want to compress the median nerve as it comes out on the bone here. Once the sleeve is applied with the help of the circulator and maintaining sterile technique, an s-hook is attached to the D-ring into the upper white and lower yellow traction cable ring. Note that the white and yellow cables are permanently joined at this ring at this point. Traction weights are applied to the end of the traction cable. The amount determined by the needs of the procedure. For routine shoulder arthroscopy, 8 to 12 pounds of weight is given to the upper traction cable or white cable, which places the arm in 70 degrees of abduction. We use 70 degree abduction position with about ten degrees of forward flexion. So the arm is just a little bit in front of the body and up about about 70 degrees. You can go up or down a little bit if you want. But the reason we go forward with the arm is because we always tilt the patient on the table backwards just a little bit. So the balance between the arm being forward and the patient tilted back just a little bit gives us a nice stable position. For subacromial decompression and distal clavicle resection. Ten degrees of abduction and 5 to 10 degrees of forward flexion are used. This is accomplished by hanging 8 to 12 pounds of weight on the lower yellow traction cable. When the arm is given 70 degrees of abduction, the view within the subacromial space is not optimal. When the arms in 70 degrees of abduction, which is the best position to look in the joint, the rotator cuff is is easy to see. It's it's relaxed and the fluid fills it. It's easy to look around the shoulder and do slap lesions and things like that. But when you go into the Bursa, if you leave the arm in 70 degrees of abduction, the tuberosity, the greater tuberosity is is jammed up under the under the acromion. So what we do is we take the arm. If the acromion is this way, we take the arm and we take it out of abduction, and we move it down into a position of less abduction. And the greater tuberosity, which is like my knuckles here is rotated down, away. So then the bursal space is much, much more accessible. The way we do that is, of course, just to change the weight from the white cable to the yellow cable and down it goes. For optimal access for arthroscopic rotator cuff repair. The traveling pulley is positioned for 30 degrees of abduction. I think one thing that is a little confusing, when people first get Ahold of the three point traction system, the star system is the traveling pulley. When do you use it? What do you do with it? When I start a case, this traveling pulley is always seated in the home position, which is up at the very top of the arm. We use it there for the diagnostic arthroscopy, but when we're in the Bursa, we want to move the traveling pulley for more optimal visualization so that when our scope is lateral, it would allow us to see the attachment of the rotator tendon on the tuberosity. If the arm's way down the tuberosity is way down, our scope is lateral. We can't see it. But if you abduct the arm a little bit to see those anterolateral tears, it's very nice. Then the way we do it is simply put on an outer glove. My circulating nurse holds up on the traction we are. It's actually the first thing she does is take one of those weights off the yellow cable, the bursal cable, and put it on the overhead cable, which is the white one, and that's the one that will be on the traveling pulley. So she's got 5 pounds on each one of those and it's kind of balanced. Then I lift up on the set pin and then slowly let it down. Generally I use either the lowermost setting or one click above it. So instead of being in say, 10 or 15 degrees of abduction, which is what I'm in with the yellow cable, I'll be in about 30 degrees of abduction. And that gives me just absolutely perfect position that I can see these lateral, particularly anterior lateral tears. It takes me a little bit out of the or a little bit into a little more forward elevation. So it puts it in a little better position for visualization. For arthroscopic bank cards. The arm is positioned in approximately 15 degrees of abduction and zero degrees of flexion, using 5 pounds of weight on the lower yellow traction cable. Also for improved visualization and access to the low 6:00 position. The lateral traction and rotation strap is applied to the upper part of the star's sleeve and connected to the lateral or red traction cable with 5 pounds of weight. If I'm going to do anterior reconstruction, I have two choices. If the shoulder is really, really loose and I've got a good look in the standard arthroscopy position, I'll go ahead and do my reconstruction in that manner. Most often, though, I prefer to put it in two point traction or the so-called gross position. What I do is then lower the arm by putting a 5 pounds of weight on the yellow, and put my lateral strap over a strip of foam from the star sleeve that I. That I put up here under the axilla. Of course, you want to be very, very careful with traction in this area because the vessels and the nerves are right right there. So we always use a big, thick piece of star sleeve, which I often will just simply cut off and advance up if the arm is long, and then put my two inch wide lateral strap on it, and then watch the the weight carefully and only use it as long as we have to use it. As soon as we're finished. Weight comes off. The lateral control strap is given 12 to 15 pounds of traction, which can be verified by the traction scale. Adjustments are made for raising and lowering the boom by cranking the black handle at the back of the three point traction system. If somebody has an extremely loose capsule, you can do the whole reconstruction with the arm in the standard arthroscopy position. Probably what you'll be doing is doing some posterior capsular stitching and as a supplement to supplement to your anterior repair and the posterior capsule stitching I always like to do, and the inferior capsular plication stitches I always like to do with the arm and abduction 70 degrees. I don't want to have the arm adducted or close to the body, because that that allows the the capsule to be very loose. And when the capsule is loose, you have a tendency to take way too much tissue when you do your stitches. And then when you go to move the arm back up, it's too tight. But if the arm is already in 70 degrees of abduction and the scapula is rotated a little bit, then you can take up just the redundant capsule when you do your stitching. For many open and arthroscopic rotator cuff repair, it is sometimes an advantage to have the rotational control while repairing the supraspinatus to the greater tuberosity. I think it's important to have a three point system, because sooner or later you'll be in a situation where you'll need it. And like I say, the two point system is necessary for instability surgery. When you use lateral traction and the third point is necessary for the traveler pulley, the so-called adjustable pulley for viewing in the Bursa. When your scopes in the lateral portal and you're looking at a rotator cuff tear that's lateral down more over the tuberosity, that's literally impossible to see. And instrument if you don't move the arm into that position. So I think any surgeon who's really sincerely interested in in doing shoulder arthroscopy should give it a look.

Arthrex 3-Point Shoulder Distraction System & S.T.a.R.™ Sleeve

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