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