By Brian J. Cole, MD, MBA, and Stephen J. Lee, BA
With improved understanding of rotator cuff pathology and the availability of arthroscopic instrumentation specifically designed for soft tissue repair techniques, rotator cuff repairs have evolved from a classic open approach to a mini-open (or deltoid-sparing) approach, and finally to an all-arthroscopic technique. Benefits of arthroscopic rotator cuff repair include decreased pain, avoidance of deltoid manipulation, and optimization of the rehabilitation process.
Indications
Indications for arthroscopic repair are similar to those with other approaches. Decision-making must take into account the following:1,2 (1) Size of tear and degree of retraction. Initially, arthroscopic repair was limited to small to medium tears (< 5 mm) with < 2 cm of retraction.2,3 With improved arthroscopic techniques for mobilization and suture placement, the indications now include larger tears. (2) Quality of tissue. The cuff tendon must securely hold suture. (3) Quality of bone. Similarly, the bone must allow for secure anchor fixation. The skills of the surgeon must also be taken into consideration, as this is a technically demanding procedure.
Patient Positioning / Portal Placement
Although the lateral decubitus position may be used, I prefer the beach-chair position due to its ease of setup, familiar orientation, and capability to convert to an open procedure. Standard 3-portal arthroscopy is performed. A fourth accessory anterolateral portal is established about 5 mm off the anterolateral corner of the acromion to facilitate anchor placement, suture management, and most importantly, arthroscopic knot tying.
Operative Technique
A systematic evaluation of the glenohumeral joint is followed by subacromial decompression. Accurate recognition of the tear pattern (crescent, "U", "L") helps determine the most effective treatment strategy. Crescent-shaped tears are repaired by reattaching the free margin directly to bone with sutures from laterally placed suture anchors. For U- and L-shaped tears, side-to-side suture placement from medial to lateral (margin convergence) is followed by securing the lateral tendon edge and anterolateral corner (L-shaped tear) to bone using suture anchors.
Margin Convergence4 (see Figure 1)font>
Method 1—Anterograde Suture Passage. A soft-tissue penetrator loaded with braided suture is passed through the posterior portal, penetrating both the posterior and anterior leaflets simultaneously. A crochet hook passed through the anterior portal retrieves the suture limb from the penetrator and the trailing limb from the posterior leaflet. The suture is then tied in line through the anterior portal.
Method 2—Anterograde Suture Hand-Off. A soft-tissue penetrator loaded with braided suture is passed through the posterior portal penetrating only the posterior leaflet, and a second penetrator is placed through the anterior portal meeting in the middle of the field of view. The suture is then dropped by the posterior penetrator and picked up by the anterior penetrator and pulled out the anterior portal. The remaining steps are similar to Method 1.
Method 3—Retrograde Suture Shuttle. A suture shuttling device loaded with a #0 or #1 monofilament suture is used to shuttle a suture through the posterior and anterior leaflet. The monofilament suture is then advanced and retrieved through the anterior portal by the crochet hook. A permanent suture is then tied to the free monofilament suture end outside the anterior portal, and the shuttling device and monofilament are withdrawn through the posterior portal. This effectively "shuttles" the permanent suture through both leaves of the rotator cuff. A crochet hook passed through the anterior portal retrieves the suture limb from the posterior leaflet. The suture is then tied in line through the anterior portal.
Method 4—Retrograde Suture Shuttle Hand-Off. A suture shuttling device loaded with a #0 or #1 monofilament suture is passed through the posterior portal through the posterior leaflet. A straight soft tissue penetrator is placed through the anterior portal and the anterior leaf of the rotator cuff to retrieve the monofilament suture as it is advanced through the shuttle. The remaining steps are identical to Method 3.
Anchor Placement and Suture Management
Anchors are placed from posterior to anterior approximately 5-10 mm lateral to the articular surface of the humerus and at a 45° angle in order to increase resistance to pull-out.5 Separating each anchor by approximately 5-8 mm will proportionally distribute fixation over the entire insertion site and minimize excessive tension at any single fixation point.6,7 Optimal suture management is achieved by placing 1 anchor at a time, securing the tendon to the bone with both sutures before placing the next anchor, and using the accessory anterolateral portal as a dedicated knot-tying portal. Suture tying is always performed through cannulas, but suture-passing devices can be passed directly through skin portals. Sutures are retrieved through soft tissue using penetrating or shuttle devices as depicted in Figure 2.
Results
Early results from arthroscopic repair of full-thickness cuff tears were satisfactory and paralleled the results reported for traditional open repair. Several recent follow-up studies corroborate these results. Gartsman and associates8 reported on 73 arthroscopic rotator cuff repairs with a mean follow-up of 30 months resulting in 84% good or excellent outcomes. Burkhart and colleagues9 published results of 59 arthroscopic rotator cuff repairs with an average follow-up of 3.5 years leading to 95% good or excellent results, regardless of tear size. Murray and associates10 studied 48 arthroscopic repairs with 2-6 year follow-up, which resulted in 46 good or excellent results and 1 failed repair. These medium-term follow-up studies lend further support to the position that arthroscopic rotator cuff repairs can provide outcomes and patient satisfaction similar to or greater than those achieved by open repair in the hands of an experienced shoulder arthroscopist.
References
1. Yamaguchi K, et al. Transitioning to arthroscopic rotator cuff repair: The pros and cons. J Bone Joint Surg Am. 2003; 85A:144-155.
2. Stollsteimer GT, Savoie FH 3rd. Arthroscopic rotator cuff repair: Current indications, limitations, techniques, and results. Instr Course Lect. 1998;47:59-65.
3. Baker CL, Liu SH. Comparison of open and arthroscopically assisted rotator cuff repairs. Am J Sports Med. 1995;23:99-104.
4. Mazzocca AD, Cole BJ, Romeo AA. Arthroscopic repair of full-thickness rotator-cuff tears: Surgical technique. Op Tech Orthop. 2002;12:167-175.
5. Burkhart SS. Technical note. The deadman theory of suture anchor: Observations along a South Texas fence line. Arthroscopy. 1995;11:119-123.
6. Burkhart SS. A stepwise approach to arthroscopic rotator cuff repair based on biomechanical principles. Arthroscopy. 2000;16:82-90.
7. Burkhart SS. Reconciling the paradox of rotator cuff repair versus debridement: A unified biomechanical rationale for the treatment of rotator cuff tears. Arthroscopy. 1994;10:4-19.
8. Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator-cuff. J Bone Joint Surg Am. 1998;80:832-840.
9. Burkhart SS, Danaceau SM, Pearce CE Jr. Arthroscopic rotator cuff-repair: Analysis of results by tear size and by repair technique-margin convergence versus direct tendon-to-bone repair. Arthroscopy. 2001;17:905-912.
10. Murray TF Jr, et al. Arthroscopic repair of medium to large full-thickness rotator cuff tears: Outcome at 2- to 6-year follow-up. J Shoulder Elbow Surg. 2002;11:19-24.
Stephen J. Lee, BA, Northwestern University Feinberg School of Medicine, Chicago, Ill.
With improved understanding of rotator cuff pathology and the availability of arthroscopic instrumentation specifically designed for soft tissue repair techniques, rotator cuff repairs have evolved from a classic open approach to a mini-open (or deltoid-sparing) approach, and finally to an all-arthroscopic technique.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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