ARTHROSCOPIC ROTATOR CUFF REPAIR

Arthroscopic Rotator Cuff Repair

Stephen J. Snyder and Christopher A. Foetisch

Arthroscopic techniques have evolved over the last 15 years to the point where now most, if not all, repairable rotator cuff tears can be repaired arthroscopically. In the early 1980s, the arthroscope was used only for evaluation and diagnosis and debridement in the shoulder. It proved to be a valuable tool to improve patient care with more accurate diagnoses, especially in areas of undersurface partial cuff tears. As surgical instruments and skills improved, the important task of performing a subacromial decompression and distal clavicle resection arthroscopically became possible and soon proved to be superior to the standard open methods. This progress eliminated the need for detaching the deltoid muscle and provided the surgeon the option of performing a limited lateral deltoid or “mini-open” surgical approach for a repair of complete rotator cuff tears. The natural progression of the state of the art of shoulder surgery to completely closed rotator cuff repair was made possible by the introduction of specialized miniature suture anchors and suture-passing tools. Using these devices, a surgeon now has the necessary equipment to evaluate, decompress, mobilize, and repair almost any rotator cuff tear that has an adequate component of viable tendon tissue.

Indications

Indications are symptomatic rotator cuff tear.

Contraindications

1. Painless rotator cuff tear with near full-functional active range of motion

2. Inability to perform postoperative therapy

3. Magnetic resonance imaging (MRI) evidence of massive irreparable tear or muscle atrophy and degeneration

4. Significant medical illness

5. Osteoporosis

Mechanism of Injury

Generally results from an attritional tear of the rotator cuff tendons with or without subacromial impingement. Occasionally occurs as a result of a traumatic injury, generally in the setting of a previously diseased tendon with a final traumatic insult.

Physical Examination

1. Limited active range of motion and/or weakness and pain with supraspinatus and external rotation testing

2. Supraspinatus and infraspinatus muscle atrophy

3. Positive impingement test

Diagnostic Tests

1. Standard radiographic shoulder series consisting of a true anteroposterior, axillary, subacromial outlet, and acromioclavicular joint view

2. MRI scan consisting of coronal oblique, sagittal, and axial cuts on a 1.5 Tesla scanner with a dedicated shoulder coil

Preoperative Planning and Surgical Timing

1. A period of nonoperative treatment may be indicated for small unretracted tears.

2. For all other tears we recommend surgical repair as quickly as possible to limit pain, further atrophy, and tendon retraction and subsequent disability.

Special Instruments

1. Revo® 4-mm and Super Revo® 5-mm titanium screw-in suture anchors (Linvatec Inc., Largo, FL)

2. Revo® anchor insertion equipment (Linvatec, Inc, Largo, FL)

3. Spectrum suture hook set (Linvatec, Inc, Largo, FL)

4. Shuttle Relay® (Linvatec, Inc, Largo, FL)

5. Three-point shoulder distraction system (Arthrex, Naples, FL)

6. STaR® sleeve (Arthrex, Naples, FL)

7. Linvatec arthroscopy pump (Linvatec, Inc, Largo, FL)

8. Complete arthroscopic equipment set

9. 5.5 mm operating cannulas

10. Multicolored #2 nonabsorbable suture

11. Panacryl® suture size #2 (Johnson & Johnson, Somerville, NJ)