FULL-THICKNESS TEARS: ARTHROSCOPIC REPAIR

https://doi.org/10.1016/S0030-5898(05)70267-4Get rights and content

Section snippets

INDICATIONS

The indications for arthroscopic rotator cuff repair are identical to those for an open repair and should not in any way be altered or broadened in the mistaken view that arthroscopic repair is a lesser procedure. Although the skin incisions may be smaller and the deltoid left attached, all elements of an open repair are performed arthroscopically, and patients who are unable to tolerate either the surgery or postoperative rehabilitation of an open procedure are not candidates for an

ANESTHESIA

The authors use interscalene block anesthesia supplemented with general anesthesia. Regional anesthesia permits a decreased use of anesthetic agents, which minimizes postoperative side effects and allows for excellent pain relief in the postoperative period so that physical therapy can be instituted.2 General anesthesia eliminates patient discomfort on the operating table and unwarranted movement. It also effectively eliminates unnecessary conversation.

POSITIONING

The beach chair position is preferred as the orientation of the shoulder is familiar to that seen during open procedures, and easy access is afforded to the anterior, lateral, and posterior aspects of the shoulder. Patient position is greatly facilitated by the use of the Schloein patient positioner, and the arm is controlled with a McConnell arm holder. The Schloein apparatus speeds patient positioning and allows excellent access to the posterior shoulder without translating the patient off

PORTALS

Three portals are used. The posterior portal is 1.5-cm medial and 1.5-cm inferior to the posterolateral acromial border. The lateral portal is made just posterior to the anterior acromial border approximately 5 cm lateral to the acromion, and the anterior portal is made midway between the acromioclavicular joint and the anterolateral acromion. The posterolateral portal is made superior to the traditional point of entry in the “soft spot” so that the arthroscope enters the subacromial space

INSTRUMENTS

Several specialized arthroscopic instruments are useful in this procedure. The original Caspari suture punch has been modified by Snyder to include an open tip that allows passage of the sutures and a bend in the jaws to allow better tissue penetration. The needle tip is 4 mm long. The senior author (GMG) has not found this adequate to penetrate the rotator cuff tendons; therefore, the punch has been modified so that the needle is 6 mm long, and the bend is eliminated. This allows the punch to

SURGICAL TECHNIQUE

The operation begins with an examination under anesthesia to determine range of motion and stability. Glenohumeral joint inspection is performed. The rate of glenohumeral joint abnormalities in patients with rotator cuff tears has been reported to be 80%, but, in the author's experience, the rate of significant abnormalities that alters diagnosis or treatment is 20%. Joint abnormalities include biceps tendon tears (partial or complete), labrum tears, labrum separations superior labrum anterior

SUBACROMIAL SPACE

The arthroscope is redirected through the same skin incision into the subacromial space. Usually, the space is easily visualized. The lateral portal is identified with a spinal needle and a cannula inserted. At first, the goal is to clear the subacromial space of bursitis that obscures visualization without altering the appearance of the rotator cuff or acromion. A power shaver is used. The bursa is removed to allow visualization in the subacromial space, to remove space-occupying lesions, and

TEAR CLASSIFICATION

The arthroscope is then rotated so that it is pointed directly down at the rotator cuff tear. With small-to-medium tears, the size and tear geometry are easily appreciated. The tear size is measured using the known diameter of the lateral cannula for direct comparison. The length of the tear from anterior to posterior as well as the amount of medial retraction are noted. Straight medial retraction or retraction in an elliptical shape is the most common finding. As tear size increases, the

IRREPARABILITY

Occasionally a tear is irreparable. In the author's practice, this occurs in approximately 8% of surgical cases. The tear is suspected to be irreparable if on clinical examination there is significant atrophy in the infraspinatus fossa and extreme weakness to resisted external rotation, usually less than 5 pounds when measured with a dynamometer. Findings of MR imaging include muscular atrophy of the rotator cuff muscles, superior migration of the humeral head, and retraction of the tendon edge

CORACOACROMIAL LIGAMENT

Coracoacromial ligament resection is better than simple division. Too often at revision surgery, the coracoacromial ligament is found to be intact when the operative report describes simple ligament division. The coracoacromial ligament is divided at its lateral insertion point on the acromion. The author prefers to use electrocautery or the holmium laser because of the inconvenient location of blood vessels in this area. Once the lateral margin of the ligament has been released, dissection is

ACROMIOPLASTY

The goal of acromioplasty is to increase the size of the subacromial space. Type 2 and 3 acromions are converted to flat type 1 acromions. Any anterior osteophyte is removed so that none of the acromion projects anterior to the anterior border of the distal clavicle. If the acromion has a lateral slope as identified on MR imaging or plain radiographs, the inferior lateral acromion is further thinned. The details of arthroscopic acromioplasty are described in the literature.4, 5

ACROMIOCLAVICULAR JOINT

After the medial acromion has been removed and the acromioplasty completed, the acromioclavicular joint comes into view. If preoperative imaging has detected inferior osteophytes, the inferior one half to one third is removed with a power bur. If the patient has symptoms referable to acromioclavicular joint arthritis on preoperative history and examination, an acromioclavicular joint resection is performed. Both bursal and direct joint techniques have documented records of success and are

CUFF MOBILIZATION

Adhesions may have formed within the subacromial space between cuff and acromion or cuff and deltoid, interfering with tendon mobilization. Adhesions to the coracoid or coracohumeral ligament contracture may falsely give the impression of irreparability. The adhesions must be released to enable mobilization.

Posterior adhesions usually are not dense, and the author can frequently release them by inserting a metal trocar and cannula through the lateral portal, placing it superior to the anterior

SITE PREPARATION

The next step is preparation of the bone surface at the repair site. A 4-mm round bur is used to prepare a cancellous bed for the tendon. A total of 1 to 2 mm of bone is removed until cancellous bone is visible. The tendon is not placed in a trough. The site of bone preparation is based on tendon mobility. If an anatomic repair is possible, the bone is prepared just medial to the greater tuberosity. The length of the bone preparation site is determined by the length of the tendon tear. The

ANCHOR SELECTION

The ideal suture anchor would have the following characteristics:

  • 1

    It would allow firm fixation in the greater tuberosity.

  • 2

    The surgeon would be able to select which suture is loaded on the anchor.

  • 3

    The anchor would be inserted under hand control without the need for predrilling or power instruments.

  • 4

    The suture would slide in the anchor.

  • 5

    The anchor would be removable from the bone in the event of suboptimal placement or suture breakage.

  • 6

    The anchor would be fixed securely to the inserting device so

SUTURE SELECTION

No. 2 braided nonabsorbable suture is used for rotator cuff repair. Because the management and identification of sutures within the subacromial space can be difficult, it is advantageous to select different colored sutures. The author uses the three-suture pack from Ethicon (Somerville, NJ) (D-6090 special order), which contains white, dark green, and light green No. 2 sutures. The white suture is placed most anteriorly and the dark green further posteriorly; the most posterior suture is pale

ANCHOR PLACEMENT

The number of anchors used is dependent on the length of the rotator cuff tear. For all but the smallest tears, the author uses two anchors. Tears involving two or more tendons generally require three to four anchors. The anchors are placed lateral to the greater tuberosity for the following reasons:

  • 1

    The anchor is placed in bone with an intact cortical surface compared with the prepared bed of the repair site.

  • 2

    Lateral placement allows the anchors to be positioned so that the line of tendon

SUTURE MANAGEMENT

Perhaps the most difficult part of an arthroscopic rotator cuff repair is suture management. Multiple strands of suture within the subacromial space can be confusing, and suture strands can interfere with the placement of subsequent sutures within the tendon. Two periods occur during which suture management is critical. The first is when the anchors are placed in the bone and the second as each suture is passed through the torn tendon. The surgeon should work out which method works best for him

SUTURE PLACEMENT

Once suture anchor placement has been completed, the braided sutures must be passed through the torn tendon. The soft-tissue grasper is passed through the lateral cannula, and the precise location for the tendon repair as well as the location and spacing of each suture are estimated. The sutures should be evenly spaced from the anterior tendon edge to its posterior margin. The sutures are placed approximately 5 mm from the tendon edge. The author begins suturing anteriorly and works posteriorly

SUTURE PASSING

The Caspari suture punch will accept only monofilament suture. The Linvatec shuttle relay will fit in the punch and allow for braided, permanent suture to be passed through the tendon. However, the shuttle relay is expensive ($28) and has a tendency to twist. The wire strands can be difficult to separate. The author currently uses a 2-0 nylon suture that is folded in half. The two free ends are passed into the suture punch, and the loop end exits from the handle. The tendon is grasped and

KNOT TYING

Arthroscopic knot tying can be a frustrating experience that is only overcome with practice. A few fundamentals may ease the process. The surgeon should always make certain that no tangles exist. The suture retrieval forceps should be passed through the knot-tying cannula and used to grasp one suture. The forceps is then withdrawn out the cannula. This will separate any suture wrapping. The author grasps the suture that exits from the bursal cuff surface. This bursal suture is then passed

POSTOPERATIVE MANAGEMENT

Postoperative management is identical to that with an open repair. The patient is placed in a sling except for those periods when the continuous passive motion machine moves the arm in elevation and then into external rotation. The safe limits of movement are determined at the time of surgery and are documented. Passive motion by a physical therapist, again in elevation and external rotation, is started when the patient is brought to the hospital room. The therapist also educates the patient in

RESULTS

As complete arthroscopic rotator cuff repair is a relatively new procedure, little information has been published to guide the surgeon. Snyder8 has reported early promising results with his technique. My experience in 200 arthroscopic rotator cuff repairs is that such procedures equal the results of open repair or mini-open repair. This is not surprising, as the operations are fundamentally similar and the postoperative rehabilitation identical.

DISCUSSION

The performance of arthroscopic rotator cuff repair is based on the foundation that all elements of an open repair can be accomplished arthroscopically. The individuals who have taken arthroscopic rotator cuff repair from theory to reality are all expert technicians with a thorough understanding of the fundamentals of rotator cuff repair. Whether an arthroscopic cuff repair has good long-term results when compared with an open procedure remains to be seen, and we await the publication of

First page preview

First page preview
Click to open first page preview

References (8)

There are more references available in the full text version of this article.

Cited by (64)

  • Small supraspinatus tears repaired by arthroscopy: Are clinical results influenced by the integrity of the cuff after two years? Functional and anatomic results of forty-six consecutive cases

    2012, Journal of Shoulder and Elbow Surgery
    Citation Excerpt :

    Tears were repaired to the bone by suture anchors. The anchors were inserted at an angle of approximately 45° to increase the anchor’s resistance to pullout.6,13 An average of 1.4 anchors (range, 1-4 anchors) was used per cuff repair, depending on the size and the shape of the tear.

View all citing articles on Scopus

Address reprint requests to Gary M. Gartsman, MD, Fondren Orthopedic Hospital, Texas Orthopedic Hospital, 7401 South Main Street, Houston, TX 77030

*

From the Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas

View full text