- Discussion: - see: rotator cuff, open rotator cuff repair, and massive RTC - etiology of RTC tears and how do these tears heal? - Technique: - arthroscopy exposure and setup: - ref: The Accessory Posteromedial Portal Revisited: Utility for Arthroscopic Rotator Cuff Repair - other considerations: - distal clavicle excision / biceps tendon and slap tear - references: - Concomitant Arthroscopic SLAP and Rotator Cuff Repair - Arthroscopic Biceps Tenodesis Incorporated Into Rotator Cuff Repair Using Suture Anchors - Asymptomatic acromioclavicular joint arthritis in arthroscopic rotator cuff tendon repair: a prospective randomized comparison study. - No advantages in repairing a type II SLAP lesion when associated w/ RCT in patients over age 50: a randomized controlled trial -The effect of rotator cuff tears on surgical outcomes after type II SLAP tears in patients younger than 50 years.
- preparations prior to repair: - visualization: - immediately after prepping, infiltration of SA space with 0.5% lidocaine or marcaine plus epinephrine (1:200,000) will reduce bleeding; - anterolateral traction will impove the viewing area, and facilitate procedure; - consider insertion of 8 mm (large) cannula into the posterolateral portal (this is the most narrow portion of acromio-humeral interaval and therefore insertion of large cannula into this area will expand AH interval; - accessory anterolateral portal; - allows better triangulation (than lateral portal) for approach to supraspinatus; - needs to be placed as superior as possible; - references: - Subacromial internal spacer for rotator cuff tendon repair: "the balloon technique". - A Simple Way to Improve Visualization and Increase Working Space in Arthroscopy: The Pull-String Technique - subacromial bursectomy - needs to be compulsive and complete for appropriate visualization; - there needs to be complete removal down to the subdeltoid space; - there should be complete visualization 1 cm medial to both the anterior and posterior arthroscopic portals; - arthroscopic acomioplasty - references: for rotator cuff repair without acromioplasty - Improvement in Comfort and Function After Cuff Repair Without Acromioplasty - Open rotator cuff repair without acromioplasty. - Arthroscopic rotator cuff repair with and without arthroscopic subacromial decompression: a prospective, randomized study of one-year outcomes. - Débridement of Partial-Thickness Tears of the Rotator Cuff without Acromioplasty. Long-Term Follow-up and Review of the Literature - SAD with Acromioplasty and Structured Exercise Was No More Effective and Was More Expensive Than Exercise Alone - Arthroscopic rotator cuff debridement without decompression for the treatment of tendinosis. - Subacromial denervation as a treatment modality for patients with subacromial pathology Cuff Repair Techniques - assessment of cuff tear / cuff mobilization / restoration of the foot print / convergence repair - note intervening bare area between the articular margin and the infraspinatus and teres minor - required steps: - there are several steps for arthroscopic cuff repair and each step needs to be optimally performed w/o interfering w/ other steps; - speed screw meets all of these requirements; 1) passage of sutures for optimal tendon grasp: - (core tendon repair techniques) dont forget the contributions of the hand sugeons to tendon repair; (knot tying tech) - remember that the main cause of rotator cuff repair failure is when the suture pulls through the tendon; - references: - Mode of failure for rotator cuff repair with suture anchors identified at revision surgery. - Medial Versus Lateral Supraspinatus Tendon Properties. Implications for Double-Row Rotator Cuff Repair - An arthroscopic stitch for massive rotator cuff tears: the mac stitch
- consider articular sided suture passage (using a cresent shuttle passer); - shuttle passer is passed through the anterolateral portal down through the supraspinatus (viewed from the joint side) - soft tissue biceps tenodesis can be performed by incorporating the biceps tendon against the supraspinatus (with several passes of the shuttle), and following this the biceps is released; - references: - Biomechanical evaluation of arthroscopic rotator cuff stitches. 2) bone anchor insertion - this step takes into consideration restoration of the footprint and optimally making sure that the tensioned cuff is draped over the anchor site; 3) tensioning of sutures (mobilization of cuff) 4) locking of sutures to anchor (rather than locking of the sutures against bone vs using knots) 5) supplemental medial knots: - Comparison of mechanical stability in double-row rotator cuff repairs between a knotless transtendon construct versus the addition of medial knots.
- Single Row Technique: - one row of anchors is placed in the greater tuberosity usually lateral to the rotator cuff footprint - references: - Comparative Analysis of Single-Row Versus Double-Row Repair of Rotator Cuff Tears - Arthroscopic Transosseous Rotator Cuff Repair - Arthroscopic Rotator Cuff Repair Using a Tension Band Suture Technique - Biomech comparison of double-row versus transtendon single-row suture anchor technique for repair of grade III partial articular-sided RCT - In situ transtendon repair outperforms tear completion and repair for partial articular-sided supraspinatus tendon tears - Biomechanical analysis of a knotless transtendon interimplant mattress repair for partial-thickness articular-sided rotator cuff tears
- Double Row Technique: - one row of anchors are placed at the articular margin and the second row is placed lateral to the footprint - transosseous equivalent - one row of anchors is placed at the articular margin then laid down on top of the rotator cuff and secured to a lateral row of anchors; - differs from double row in that one set of common sutures is shared between the two rows of anchors and it acts to compress the rotator cuff on the native footprint rather than “spot weld”. - references: - Humeral head osteonecrosis following arthroscopic rotator cuff repair. - Early pullout of lateral row knotless anchor in rotator cuff repair - Impingement syndrome of the shoulder following double row suture anchor technique for arthroscopic RCR: - Double Row Cuff Repair A review of the literature - Medial Rotator Cuff Failure After Arthroscopic Double-Row Rotator Cuff Repair - Arthroscopic Triple-Row Rotator Cuff Repair: A Modified Suture-Bridge Technique - Impingement syndrome of the shoulder following double row suture anchor technique for arthroscopic rotator cuff repair: a case report - Factors affecting healing rates after arthroscopic double-row rotator cuff repair - Complications: - Incidence and treatment of postoperative stiffness following arthroscopic rotator cuff repair. - Upper Airway Compromise by Extravasated Fluid: A Rare Complication After Arthroscopic Repair of Atrophic Cuff Tear - The Long-Term Outcome of Recurrent Defects After Rotator Cuff Repair.