Radiographs of shoulder. (a) AP view and (b) axillary view of left shoulder demonstrate concentric glenohumeral joint with no evidence of glenohumeral arthritis or proximal humeral migration
MRI of shoulder. (a) Coronal T2 image demonstrates full-thickness rotator cuff tear. The tear involved supraspinatus and the anterior portion of the infraspinatus. (b) Sagittal T1 image demonstrates no evidence of rotator cuff atrophy or fatty infiltration
The patient’s history, physical examination, and diagnostic imaging are consistent with an acute symptomatic full-thickness rotator cuff tear. This was discussed with the patient including options for continued nonoperative treatment or consideration of rotator cuff repair. With regard to pursuing nonoperative treatment, the risks of tear-size progression and specifically possible progression of a repairable tear to an irreparable tear and possible development of irreversible muscle atrophy and fat infiltration were discussed. With regard to pursuing operative treatment, risks of infection, stiffness, and failure of rotator cuff repair were discussed. Based upon the patient’s age, occupation, acute onset of injury, and failure of improvement with prior nonoperative treatment, he opted to proceed with rotator cuff repair.
Our preferred surgical technique for repair of small, medium, large, and even massive full-thickness rotator cuff tears, which can be appropriately mobilized to the anatomic footprint, is to utilize an all-arthroscopic suture-passing device that enables the surgeon to pass sutures transosseously via a tunnel between medial based and lateral based holes in the greater tuberosity (Tornier © Arthrotunneler device (Amsterdam, The Netherlands)) (Fig. 4.3). Each tunnel can accommodate three to four sutures. With the sutures placed transosseously, the surgeon can then proceed with passage of suture limbs through the rotator cuff tendon, followed by securely tying down the tendon to the greater tuberosity footprint, thus generating a true-transosseous rotator cuff repair.
Image of tunneler instrumentation . (a) Drill guide and trocar—used for drilling medial tunnel holes, (b) stick suture passer, (c) awl with hard stop, (d) drill for medial hole with hard stop, (e) drill for lateral hole, (f) tunneler
We perform arthroscopic rotator cuff repair in the beach-chair position under general anesthesia with a regional block. The operative arm is held with a pole (McConnell Orthopedic Manufacturing, Greenville, TX) that is utilized to support the arm in various ranges of shoulder abduction and external rotation to bring different areas of the greater tuberosity into view and in-line with the trajectory of instruments during the surgery.
We begin with a standard posterior portal and a diagnostic arthroscopy to evaluate the condition of the glenohumeral joint. Careful attention is paid to the subscapularis tendon, and if repair is indicated, it is performed prior to transitioning the scope to the subacromial bursa. After completion of the diagnostic arthroscopy and any possible biceps tendon, subscapularis, or other glenohumeral joint treatment, the scope is directed into the subacromial bursa. Once in the subacromial bursa, a spinal needle allows for localization of the lateral portal, which is made horizontal. It is critical that the superior-to-inferior height of the lateral portal is not too high, or it can make the use of the arthrotunneler device more difficult. Our preference is that a spinal needle, held in a horizontal position, should just skim the top surface of the greater tuberosity, when the shoulder is in a neutral position.
The next phase of the operation is obtaining optimal visualization of the rotator cuff tear to allow for assessment of tear size and configuration. The subacromial bursa is resected with a combination of shaver and electrocautery devices; acromioplasty is not routinely performed. The footprint of the rotator cuff is debrided and lightly decorticated with the use of an arthroscopic burr to help stimulate a healing response. Although tendon mobilization is not typically a problem for small- to moderate-sized tears, it is important to perform appropriate releases for retracted tears to allow for maximal tendon excursion and to minimize tension on the repair. The anterior-to-posterior size of the rotator cuff tear is utilized as a guide for the number of tunnels to be placed. In general, a “two-tunnel” suture configuration is utilized for tears 1–2 cm in anterior-to-posterior size. For larger tears, additional tunnels can be utilized with a repeating pattern of suture organization and configuration.
In our two-tunnel rotator cuff repair , each tunnel contains three nonabsorbable #2 sutures; two of the sutures are utilized in a simple suture configuration, while the third suture is utilized to create a “rip-stop stitch” by creating a box suture configuration when paired with a suture from the adjacent tunnel (Fig. 4.4). For suture management purposes, we typically utilize black-striped, blue-striped, and solid-colored sutures in each tunnel. For larger tears requiring three or more tunnels, the approach is the same: the most anterior and most posterior tunnel contains three nonabsorbable sutures, and each of the central tunnels contains four nonabsorbable sutures. In cases of utilizing three or more tunnels, the more central tunnel contains an additional nonabsorbable suture to allow for a rip-stop box suture configuration to be created with a suture from the adjacent tunnel anterior and posterior to it.
A two-tunnel repair . A two-tunnel repair schematic, a lateral box stitch (blue suture) is created to serve as a rip stop for the simple sutures (blue-striped and black-striped)
A posterolateral viewing portal is created prior to beginning the next phase of the operation and allows for good visualization of the rotator cuff tear (Fig. 4.5) so that we can understand the size, retraction, and pattern of the tear as this aids us in how it will be repaired (Fig. 4.5b). A spinal needle is typically inserted into the subacromial spacer along the lateral edge of the acromion to help estimate the number and placement of the medial based tunnel holes. The process for passing the sutures transosseously begins with the use of a drill and drill guide to create the medial based holes in the greater tuberosity. This is performed through an accessory anterolateral portal with a trajectory that is roughly 70–80° upright from the footprint of the tuberosity. The placement of this portal should allow for access to create all of the medial holes by simply externally or internally rotating the arm. The drill guide is positioned on the medial edge of the footprint and the drill is advanced until the hard stop of the drill (Fig. 4.6). An awl with a hard stop is then utilized to increase the diameter of the hole and be sure that it is the appropriate depth. All of the medial holes can be placed successively before moving to the next step of passing transosseous sutures.
Rotator cuff tear before and after being reduced. Left shoulder, posterolateral viewing portal showing the rotator cuff tear (a) and it reduced on the greater tuberosity with a grasper (b)
Tunneler medial hole drilling . Left shoulder, posterolateral viewing portal; drill guide utilized to place medial drill hole, drill is advanced to a hard stop
Once all of the medial holes have been created, the lateral portal is lengthened to about 1.5 cm in length, which allows for introduction of the arthrotunneler device into the subacromial space. Beginning with the most anterior tunnel and working posteriorly, the arthrotunneler device is seated into the most anterior of the medial holes and held firmly against the tuberosity (Fig. 4.7b). It is important to properly position the tunneler such that the lateral drill holes are adequately spaced from one another. A second drill is utilized to create a horizontal hole in the lateral aspect of the greater tuberosity that intersects with the tip of the arthrotunneler device medially. A wire loop can be deployed and acts as a capture device to ensure that the two holes intersect. The wire loop is left in the deployed position and the drill is withdrawn with care not to disrupt the orientation of the arthrotunneler. Next, a suture passer with a passing stitch is then placed down the barrel of the arthrotunneler and captured with the wire loop. The suture passer is gently removed to allow the wire loop to securely hold the passing suture when the tunneler is removed.
Tunneler position and seated on medial hole. Left shoulder, posterolateral viewing portal with the tunneler guided into position (a) and the tunneler seated into medial drill hole and held flush to greater tuberosity with the inset being the external view of hand positioning for the tunneler (b)
At this point, the tunneler device is withdrawn, keeping the looped end of the passing suture captured by the wire loop. This leaves a passing suture through the tunnel which can be used to shuttle sutures of different size, type, and color according to the surgeon’s preference (Fig. 4.8a, b). For the most anterior tunnel, three nonabsorbable #2 sutures are passed with the looped passing suture. The medial and lateral tails of these nonabsorbable sutures are successively brought out of an anterior portal and tagged with hemostats. We prefer to tag the medial limbs with a single hemostat and the lateral limbs with two hemostats. Since the operation requires multiple tunnels and multiple sets of sutures for each tunnel, we use color-coded hemostats for suture management . The tunneling process and suture passage process are repeated as needed (Fig. 4.9). For the most posterior tunnel the sutures are brought out through the posterior portal.
Suture passing stitch. Left shoulder, posterolateral viewing portal with the tunneler retrieving a looped passing stitch and the inset being after the looped passing stitch is placed so that three or four sutures to be utilized in the repair can be passed (a) and the looped passing stitch is being used to pass a set of sutures into the tunnel (b)
All sutures passed into tunnels. Left shoulder, posterolateral viewing portal; all sets of sutures have been passed through their corresponding tunnels. This view shows the medial tunnel holes with their corresponding sutures. This particular example is a four-tunnel repair, where most of the anterior and most posterior tunnels each contain three sutures, while the middle two tunnels contain four sutures
The medial limbs of the sutures in each tunnel are then passed in successive fashion through the cuff tendon tissue. We prefer to pass the sutures beginning with the most posterior tunnel. The hemostat is removed from the medial limb sutures and the blue-striped suture is retrieved and passed through an appropriate posteromedial location in the tendon utilizing a jawed suture passer. Next the medial limb of the solid suture is retrieved and passed—just anterior and slightly lateral to the placement of the previous striped suture. The black-striped suture is next passed more anteriorly (in-line with the blue-striped suture, with regard to medial-to-lateral placement) (Fig. 4.10). This process is repeated with the set of sutures from the anterior tunnel, again placing the solid suture a few millimeters lateral to the placement of the striped sutures. The pair of solid sutures from each tunnel will be utilized to create the rip-stop box suture configuration.
Medial suture limbs passed through tendon. Left shoulder, posterolateral viewing portal; medial limbs of sutures are being passed through the tendon. Of note, the middle suture shown will be utilized to form the lateral box rip stop, by pairing with a similar suture from the adjacent tunnel. These rip-stop sutures are placed 1–2 mm more lateral than the sutures that will be utilized in a simple-suture configuration. Inset—external view of instrument orientation
After all of the medial limbs are passed, we begin tying the sutures by creating the rip-stop box suture configuration. To do this, the medial limbs of the solid sutures in both the anterior and posterior tunnel are retrieved through an anterior cannula. These medial suture limbs are tied together with square knots and tested to ensure that the knots do not slide. The medial tails are cut with a 1 cm tail. Subsequently, their lateral based counterparts are retrieved from the lateral portal. As the lateral limbs of the solid sutures are tensioned down, the medial knot is pulled into the shoulder and sits atop the rotator cuff. An arthroscopic grasper can be utilized to pull on the tendon edge and aid in this process. The lateral limbs are tensioned and tied against the lateral aspect of the greater tuberosity with non-sliding knots. This creates the rip-stop box suture configuration, and this horizontal mattress suture also serves as medial row fixation. The remaining suture limbs are retrieved and tied in successive fashion with a simple suture configuration (Figs. 4.11 and 4.12). The same process can be applied for larger tears with three or more tunnels, noting that a rip-stop box suture configuration is created between each adjacent tunnel.
Tying sutures . Left shoulder, posterolateral viewing portal; tying of simple suture over box rip-stop suture. Box rip-stop suture depicted by asterisk
Final repair construct. Left shoulder, posterolateral viewing portal; example of final two-tunnel rotator cuff repair—simple sutures (striped sutures) tied over the box rip-stop sutures
Our patient wore a sling and abduction pillow for 4 weeks. Then he was permitted to discontinue the sling and abduction pillow and begin a passive range-of-motion home-exercise program consisting of forward elevation and external rotation. Exercises were performed three to five times a day. He was instructed to avoid reaching, pushing, or pulling with the operative arm. Weight-lifting limits are that of a coffee cup and all use of the arm should be performed with the elbow against the side of the torso and forearm directly in front of them. At 2 months postoperatively, passive range of motion was assessed. If passive range of motion is adequate, he would continue with the same home-exercise program for another 4 weeks. If there was substantial shoulder stiffness defined as passive forward elevation <100° he would be encouraged and directed to perform the home-exercise program hourly. He was permitted to use the operative arm for light activities but is instructed to avoid lifting objects greater than a few pounds. At 3 months postoperatively he began active strengthening of the rotator cuff and continued with therapy for several more months. He was released to full activity at about 6 months.
Our patient remained out of work for the initial 2-month postoperative period and then was transitioned to a modified-duty job with restrictions to not use the operative side for any lifting, pulling, and pushing. At 3 months he began formal physical therapy with rotator cuff strengthening. From 3 to 6 months he continued to demonstrate improvement in rotator cuff strength. He was released to his regular duties at work 6 months after the surgery.
Rotator cuff tears are a co mmon shoulder condition for middle-aged and older patients and often occur as a result of age-related degenerative attrition [1–5]. The prevalence of asymptomatic full-thickness rotator cuff tears may be 20% in the general population, but increases with patient age—more than 50% of patients over age 80 may have an asymptomatic full-thickness rotator cuff tear . Over time, asymptomatic rotator cuff tears may cross over to becoming symptomatic rotator cuff tears, which may be heralded by the development of pain, weakness, and functional limitations . In the appropriate scenario, repair of a full-thickness rotator cuff tear is indicated when a patient continues to have limitations despite a trial of nonoperative management or when an active patient presents acutely with a traumatic rotator cuff tear.