5 Arthroscopic Rotator Cuff Repair

10.1055/b-0039-167654

5 Arthroscopic Rotator Cuff Repair

Christos D. Photopoulos, Carola F. van Eck, and Orr Limpisvasti

Abstract

Rotator cuff pathology is a common cause of pain and dysfunction in the shoulder, and it is well known that the incidence of rotator cuff disease increases with age. Rotator cuff repair is one of the most commonly performed procedures in the United States, and over the past two decades, the field of orthopaedic surgery has witnessed the evolution of surgical approaches, techniques, and constructs involved in rotator cuff repair. Although commonly performed, arthroscopic rotator cuff repair can be a technically challenging procedure, even for experienced orthopaedic surgeons. The goal of this chapter is to outline a preferred technique for arthroscopic rotator cuff repair and to provide tips for success in preoperative, intraoperative, and postoperative management.

5.1 Goals of Procedure

The clinical goals of arthroscopic rotator cuff repair are to alleviate patient suffering, improve pain, and restore function. Technical goals of the procedure are to restore native anatomy, ¹ achieve strong initial fixation, and maintain durable stability at the repair site until biologic healing takes place. ² ^, ³

5.2 Advantages

There are several advantages to performing an arthroscopic rotator cuff repair. The use of arthroscopy allows for a comprehensive evaluation of the glenohumeral joint. As the cause of shoulder pain and dysfunction is frequently multifactorial, arthroscopy permits the treatment of intra-articular lesions, including those involving the labrum, biceps, or articular cartilage. Other commonly cited advantages include surgeon preference and comfort, the use of smaller incisions with less soft-tissue dissection, and a minimized risk of deltoid injury seen with nonarthroscopic procedures. ² ^, ⁴ ^– ⁶

5.3 Indications

Patient symptoms are the primary driving indicators for surgical repair, as the primary function of rotator cuff surgery is to alleviate pain and functional impairment. When deciding which patients are indicated for surgery, the natural history of the disease must be discussed with the patient, and several factors must be taken into account. Generally, surgical intervention is reserved for those who have failed some degree of nonoperative management, including physical therapy, anti-inflammatories, and injection therapy. Patient age and tear chronicity are important considerations, as younger patients with acute tears are more commonly indicated for surgical repair than physiologically older patients with chronic disease. Tear size, morphology, and location are likewise of importance, as larger and full-thickness tears, especially those that involve the anterior cable, are generally more accepted for surgical repair. ⁷ ^– ⁹

5.4 Contraindications

There are few relative and absolute contraindications to surgical repair. Important preoperative factors to consider are those precluding patients from anesthesia and elective surgical intervention, including recent infections, recent illnesses, and patient comorbidities that would render necessary anesthesia difficult or dangerous. Factors such as fatty infiltration, marked rotator cuff retraction, and rotator cuff arthropathy with superior humeral head migration must also be recognized preoperatively. Factors that would prevent a successful postoperative rehabilitation program, such as a patient’s ability or willingness to comply with postoperative instructions, should also be taken into account. Factors portending a poor outcome must be taken into consideration and discussed with the patient, as alternate treatment options to surgical repair exist.

5.5 Preoperative Preparation/Positioning

In the preoperative holding area, the surgical site, including the axilla, is shaved and cleansed. Chlorhexidine (2%) is the preferred skin-preparation solution given its efficacy in decreasing the bacterial burden of the skin. ¹⁰ ^, ¹¹ Regional anesthesia, consisting of an interscalene nerve block, is commonly performed prior to surgery.

The patient is transferred to the operating table and placed atop a well-padded bean bag. After induction, the operative extremity is examined to evaluate shoulder stability and range of motion. Tip: Perform this while the patient is supine so that examination can be referenced against the contralateral shoulder. The patient is then placed in the lateral decubitus position and secured in position with bean bag suction. Together, the patient and the bean bag are translated closer to the surgeon to optimize ergonomics during the procedure; the patient is stabilized with two straight posts posteriorly and one curved post anteriorly. A careful assessment of all neurovascular structures and bony prominences must be performed. The hips are slightly abducted and externally rotated with pillows to relieve stress on the spine; the knees are flexed and padded to protect the peroneal nerves; and the upper torso and scapula are tilted toward the surgeon to assist in maintaining parallelism of the glenoid face to the floor. When positioning the patient’s head, the cervical spine should not be hyperextended, laterally bent, or rotated. Reverse Trendelenburg facilitates proper scapular positioning under traction and helps create clearance between the shoulder and the head during surgery. The arm holder should be positioned in a manner that when balance suspension is applied, the arm is held in 40 degrees of forward flexion and 40 degrees of abduction. A belt is placed to secure the patient to the table ( Fig. 5.1 ).

**Fig. 5.1 (a)** Prepping of the operative extremity with chlorhexidine soap. **(b)** Surgical setup after prepping and draping are completed.

Chlorhexidine (2%) solution is again used to clean the extremity. The sequence of draping is as follows: (1) downdrape over the body, (2) four blue towels squared around shoulder, and (3) two impervious U-drapes applied in opposing directions. Any remaining soap is then dried with a sterile towel. The drapes are sealed at the skin interface with antimicrobial adhesive strips (3M Ioban, St. Paul, MN). A sterile impervious stockinet with attachment for the balance suspension is then applied from the hand to just above the elbow. This is secured in place with an elastic compressive bandage (3M Coban), paying careful attention that no bandage is applied over the cubital tunnel and that all bony prominences are free of point compression ( Fig. 5.1 ).

Ten to 15 lb of balanced suspension is then applied to the arm. Bony landmarks, portals, and planned incisions can be drawn onto the skin if necessary. The projected portal sites should be infiltrated with local anesthetic to aid in postoperative pain control. Tip: Epinephrine may be added to the local anesthetic to reduce portal site bleeding during the surgery.

Operating room setup is important in facilitating surgical ergonomics. The operating room table may be turned to ensure there is enough room for the surgical team, while minimizing the risk of surgical field contamination ( Fig. 5.1 ). The Mayo stand (and the surgical instruments) and the arthroscopy tower are positioned on the opposite side of the operating table from the surgeon. If gravity inflow is to be utilized, a Y-connector and very firm tubing must be used to ensure maintenance of adequate pressure. Foot controls for the shaver, burr, and electrocautery should be set up prior to incision.

5.6 Operative Technique

5.6.1 Portals

To begin with, a standard posterior portal is established and a diagnostic arthroscopy is performed to assess for associated chondral, labral, bicipital, and articular-sided rotator cuff pathology ( Fig. 5.2 ). To create a working anterosuperior portal (ASP), a spinal needle is placed in an outside-in fashion through the rotator interval ( Fig. 5.3 ). The exact location of the ASP should be determined based on its function. For instance, if a distal clavicle excision is to be performed, this portal can be moved slightly medially. During the case, 7 × 70 mm threaded cannulas (Arthrex, Naples, FL) are the workhorse cannulas for all working portals. PassPort cannulas (Arthrex), whose low-profile flanges prevent cannula loss during instrument insertion and removal, can also be used.

**Fig. 5.2** Evaluation of the articular aspect of the rotator cuff through the posterior glenohumeral portal.

**Fig. 5.3** Location of the anterosuperior portal (AP) as viewed from the posterior portal. G, glenoid; HH, humeral head; B, long head of the biceps tendon; SSc, subscapularis tendon.

Intra-articular evaluation of the subscapularis tendon is critical, and if repair is required, this must be done first ( Fig. 5.4 ). To better examine the subscapularis enthesis, the humerus can be internally rotated, or a 70-degree scope may be used. During surgical repair, the assistant may be asked to perform a lever-push maneuver in order to deliver the footprint into the field of view. This is done by placing a posteriorly directed force onto the proximal humerus, while providing counter pressure to the posterior elbow.

**Fig. 5.4** Evaluation of the integrity of the subscapular tendon (SSc) from the posterior portal. G, glenoid; HH, humeral head; L, glenoid labrum.

The subacromial space is entered using the existing posterior portal. A lateral working portal is established two finger breadths lateral to the lateral border of the acromion (in line with the acromioclavicular joint from an anteroposterior standpoint). A posterolateral portal can likewise be added as needed. Tip: To avoid turbulence, keep accessory portals in the subacromial space small. In addition, avoid violation of the deltoid fascia, which can lead to fluid extravasation and soft-tissue swelling.

5.6.2 Visualization

Once in the subacromial space, a 4.0 shaver (Dissector, Arthrex) is used to perform a complete bursectomy. This not only will aid in visualization but is also effective in reducing pain, as inflamed bursal tissue has been shown to be rich with afferent nerve fibers and inflammatory mediators. ¹² ^, ¹³ Tip: This step is essential to facilitate lateral row implant placement and suture management.

Using a shaver and electrocautery (Apollo, Arthrex), the coracoacromial ligament can be dissected off the acromion to further aid in visualization. This may be done completely or partially, depending on the concern for creating instability or superior escape. An acromioplasty is then performed using a 5.5 round burr (Arthrex; Fig. 5.5 ). If a distal clavicle resection is performed, the coracoclavicular ligaments must be carefully identified and preserved. In addition, the posterosuperior capsule of the acromioclavicular joint must be left intact to preserve stability of the acromioclavicular joint. ¹⁴ ^– ¹⁷ Commonly, more bone is resected anteriorly than it is posteriorly, leading to residual posterior bony contact and continued pain. ¹⁸ ^, ¹⁹ To ensure that this does not occur, the arthroscope can be placed in an anterior portal to evaluate the symmetry of the resection. Similarly, a 70-degree scope can be used from the posterior portal in lieu of placing the arthroscope in the anterior portal. Tip: Advance the 7-mm cannula from the anterior portal into the acromioclavicular joint interval to ensure adequate and symmetric resection.