All Arthroscopic Repair: Techniques Available

Jeffrey S. Abrams, M.D.

Princeton Orthopaedic and Rehabilitation Associates

Princeton, New Jersey

I. Rotator Cuff Repair Goals:

Pain relief

Strength improvement

Functional gain

Prevent disease progression

II. Natural history of impingement syndrome

Rotator cuff tendinopathy

Partial thickness tears

Full thickness tears

Small and Medium (single tendon)

Large and Massive (multiple tendons)

Irreparable tears

III. Role of arthroscopy

Diagnostic

Interarticular debridement, repair

Subacromial decompression

Partial clavicle excision

Rotator cuff repair

IV. Biomechanical Principles of Repair

Limit superior humeral head migration

Reduce compression of cuff against acromion

Preserve external rotators (infraspinatus, teres minor)

Prevent anterosuperior subluxation through cuff defeat and decompression deficiency

V. Indications

Painful shoulder, unresponsive to conservative treatment in active individuals surgical experience in open rotator cuff surgery and shoulder arthroscopy.

Ability to:

Perform rapid subacromial decompression

Mobilize cuff tissue

Appreciate thickness and quality

Understand the shape of the tear: repair or reconstruct due to tissue loss

Familiarity with equipment:

Suture passage

Suture anchors

Knot typing techniques

VI. Steps to "All Arthroscopic Repair"

Interarticular exam —Evaluate cuff tear, biceps, labrum, articular surfaces

Capsule release of undersurface cuff (beware of suprascapular nerve)

Bursectomy —Exposure of cuff margins

Release adhesions

Mobilize cuff margins

Determine reparability

Greater tuberosity

Debride soft tissue

Gentle abrade to articular margin

Subacromial decompression

Elevate soft tissue off of acromion

Recess anterior edge

Convert to "flat" acromion

Avoid additional coracoacromial ligament and debridement

Clavicle

Leave alone

Spur excision

Distal clavicle resection

Rotator Cuff Repair (small, medium tears)

Scope is posterior, water inflow on scope

Accessory portal adjacent to acromion

Punch hole for suture anchor lateral to articular surface (5 mm)

Insert suture anchor

Choices: Metallic, absorbable

Suture sliding or not.

Single load or multiple sutures

Larger anchors if osteoporotic bone

Lateral and anterior portals for suture pass

Suture hooks and shuttle

Caspari punch and shuttle

Suture retrievers

Needle/suture pass (Anchor sew)

Pass one limb of suture through tendon edge and retrieve both ends out anterior portal

Retrieve sutures pair through lateral cannula — test sliding through anchor — knot tying

Repeat for additional sutures

Rotator Cuff Repair (large tears)

Evaluate medial extension of tear

Cuff mobilize —Posterior cuff is usually easiest

Anterior releases of coracohumeral adhesions

Side to side closure

Suture hooks and retrievers

Needle passes (Arthro-sew)

Sliding knots and close medial to lateral to reduce cuff tear size

Suture anchor placement

Tuberosity prepare

Anchors adjacent to cuff margins

Suture anchor offset —Anchors can be placed at various spacing and distance from

articular margin

Simple sliding stitches at margin

Complex woven stitch centrally to lateral anchors

VII. Post Operative

Ultrasling for four weeks

Remove for exercises 2-3 X/day

Shower in 2-3 days (dry bandages)

Supine/upright passive assist external rotation

Elbow flexion

Grip strength

Supine/upright forward flexion

Cross chest stretch

Active exercises at six weeks

Resistive exercises depends on tissue quality, mobility

Suggestions

Major commitment to techniques and available equipment

Mini open surgery, may help learning curve, i.e., perform arthroscopic steps and open to confirm anticipated outcome

Rapid decompression, cuff mobility shoulder distension may become problematic

Be practical to surgical time, expense

Practice suture pass and knot tying instrumentation on open cases

Become proficient with less suture complications