Arthroscopic Rotator Cuff Repair

Thomas R. Duquin, MD

Donald W. Hohman Jr, MD

Robert U. Hartzler, MD, MS

Dr. Duquin or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Biomet; serves as a paid consultant to or is an employee of Biomet, Integer, and Zimmer; and has received research or institutional support from Biomet and Zimmer. Dr. Hohman or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Advanced Orthopaedic Solutions and Biocomposites. Dr. Hartzler or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Arthrex, Inc.; serves as a paid consultant to or is an employee of Arthrex, Inc.; and serves as a board member, owner, officer, or committee member of the Arthroscopy Association of North America.

INTRODUCTION

Disorders of the rotator cuff are common causes of shoulder pain. Many causative factors have been implicated; the most common and central factors include age-related degeneration of the tendons, mechanical impingement, and changes in the vascularity of the rotator cuff tendon. The natural history of rotator cuff disease has been recognized as a continuum, progressing from simple tendinosis to partial- and full-thickness rotator cuff tears.¹

This chapter provides an overview of the arthroscopic management of rotator cuff pathology. Special consideration is given to the evaluation of the patient with a suspected rotator cuff tear, as well as preoperative planning, surgical management, and postoperative rehabilitation.

PATIENT SELECTION

Patients with rotator cuff disorders must undergo a thorough history and physical examination, with special attention paid to the acuity of symptoms, the nature of the pain, and the degree of functional limitations. The initial management of patients with suspected atraumatic rotator cuff pathology includes a variety of nonsurgical modalities such as activity modification, nonsteroidal anti-inflammatory drugs, physical therapy, and cautious use of corticosteroid injections (Figure 1). With these measures, symptoms will improve in most individuals. Lack of improvement after 4 to 6 weeks of nonsurgical management is an indication for advanced imaging of the shoulder, typically by MRI.

As arthroscopic techniques have improved, the indications for arthroscopic rotator cuff repair have expanded. The results of arthroscopic rotator cuff repair are comparable to those of open repair, without the disadvantage of deltoid detachment.² Anecdotal reports indicate that patients have less pain in the initial postoperative period after arthroscopic repair than after traditional open repairs. A relatively steep learning curve is associated with arthroscopic repairs of the rotator cuff, and the surgeon should have advanced skills in shoulder arthroscopy.

PREOPERATIVE SURGICAL DECISION MAKING: INDICATIONS AND CONTRAINDICATIONS

Patients with full-thickness or high-grade partial-thickness tears of the rotator cuff who have pain and limited function despite an appropriate interval of nonsurgical management are candidates for arthroscopic repair. The primary indication is for the relief of pain, with improved strength and mobility being secondary goals. Although the presence of a full-thickness rotator cuff tear does not obligate the need for repair, the patient should be counseled about the risk of tear progression and muscle atrophy resulting in an irreparable rotator cuff. Patients with asymptomatic rotator cuff tears do not need surgery but should be monitored for signs or symptoms of tear progression.

Relative contraindications to shoulder arthroscopy for rotator cuff tears are more common in clinical practice compared with absolute contraindications, and these collectively represent risk factors for predicted tendon irreparability, poor tendon healing capability, or a poor risk-benefit calculation for the proposed surgical procedure. These factors, often interrelated, include chronic or recurrent tears, tears with massive size and/or significant retraction, poor tendon quality, poor muscle quality (atrophy or fatty infiltration), profound motor dysfunction (clinical anterosuperior escape, chronic elevation or external rotation pseudoparalysis), multiple corticosteroid injections, medical comorbidities (diabetes mellitus, obesity), social factors (smoking status, Worker’s compensation claim), advanced patient age, and more.³ Some patients with varying combinations of the above factors are excellent candidates for reverse shoulder replacement (even in the absence of significant glenohumeral arthrosis) to treat the rotator cuff-deficient shoulder (eg, elderly patient with chronic elevation pseudoparalysis from a massive, recurrent tear).

On the other hand, many patients who are not good candidates for rotator cuff repair per se (presence of above risk factors) are also poor candidates for reverse
arthroplasty, usually because of age and/or activity considerations, and yet have clearly exhausted nonsurgical treatment. For those patients, shoulder arthroscopy can still be indicated because many patients benefit from rotator cuff partial repair/débridement or ancillary procedures (biceps tenotomy or tenodesis, subacromial decompression, tuberoplasty, tendon transfer, or bridging graft reconstruction).

FIGURE 1 Treatment algorithm for shoulder pain consistent with rotator cuff pathology. (Adapted with permission from Duquin TR, Sperling JW: Rotator cuff disorders, in Margheritini F, Rossi R, eds: Orthopedic Sports Medicine: Principles and Practice. Milan, Italy, Springer-Verlag, 2011, pp 211-225.)

If joint preservation surgery is chosen in the face of a complex rotator cuff tear, careful preoperative planning and patient counseling are imperative. Should the cuff be found to be surgically irreparable, the choices of ancillary procedures impact on everything from surgical time and implants to postoperative rehabilitation. Rules of thumb for this decision making include the following: open or arthroscopic-assisted tendon transfer (latissimus dorsi or lower trapezius) for younger patients who have external rotation deficiency with preserved forward elevation; partial repair/débridement/tuberoplasty for older, low-demand patients with preserved motion; superior capsular reconstruction (SCR) for younger, higher-demand patients with or without acute elevation dysfunction. Surgeon ability and experience should be considered in the preoperative planning process.

Absolute contraindications to attempted arthroscopic rotator cuff repair include the presence of acute infection, significant glenohumeral arthritis, acromiohumeral arthropathy with fixed superior migration of the humeral head, an inability to tolerate anesthesia because of medical comorbidities, or an inability to comply with postoperative rehabilitation.

PREOPERATIVE IMAGING

Radiography

Plain radiographs of the shoulder, including true AP (Grashey), scapular Y, and axillary views, should be obtained. In patients with rotator cuff impingement, subtle or nonspecific findings often are found, including sclerosis of the greater tuberosity and the undersurface of the acromion (Figure 2, A). Radiographic signs of large or massive tears include superior migration of the humeral head, which results in a loss of continuity of the Gothic arch formed by the medial neck of the proximal humerus and the inferior aspect of the glenoid neck, and a decrease in the acromiohumeral distance, which is normally greater than 6 mm.

Magnetic Resonance Imaging

MRI, including T1- and T2-weighted images in multiple planes, is the benchmark for the assessment of rotator cuff disorders. Tear pattern, size, retraction, and quality of the tendon and muscle are important factors in the determination of the ability to achieve a healed arthroscopic repair. It is important to include enough scapula on MRI so that assessment of the atrophy and fatty infiltration of the rotator cuff muscles can be performed (Figure 2, B). The tangent sign is used to quantify the degree of supraspinatus atrophy, with mixed results documented in patients with a supraspinatus muscle that does not intersect the line drawn from the scapular spine to the coracoid process⁴^,⁵ (Figure 2, C).

FIGURE 2 Imaging findings of rotator cuff pathology. A, AP radiograph of the shoulder demonstrates the radiographic signs of a rotator cuff tear: sclerosis and cystic change of the greater tuberosity and acromion (red arrows) and subtle superior migration of the humeral head, indicated by a loss of the Gothic arch (white lines). B, The greater tuberosity rotator cuff footprint (black arrow) and the torn and retracted rotator cuff tear of the supraspinatus tendon (white arrow) are seen on a T2-weighted coronal oblique MRI of a right shoulder. C, Severe atrophy of the supraspinatus indicated by a positive tangent sign (yellow line) and fatty infiltration of the infraspinatus (white arrow) are seen on a T2-weighted sagittal MRI. (Panel A reproduced with permission from Duquin TR, Sperling JW: Rotator cuff disorders, in Margheritini F, Rossi R, eds: Orthopedic Sports Medicine: Principles and Practice. Milan, Italy, Springer-Verlag, 2011, pp 211-225.)

Ultrasonography

Ultrasonography is an accepted alternative to MRI, with the added benefit of dynamic examination. This modality is extremely operator-dependent and requires considerable expertise in performing and interpreting musculoskeletal ultrasonography to ensure accurate results.

PROCEDURE

Special Instruments/Equipment/Implants Required

A description of all the available devices for arthroscopic rotator cuff repair is beyond the scope of this chapter. The essential tools include a 30° arthroscope, a fluid pump system, and standard arthroscopic instruments including suture passing, suture retrieving, and knot-tying devices; arthroscopic shavers and burrs; and a radiofrequency ablation wand. Arthroscopic cannulas and retractors can aid greatly in the operation.

Suture anchors used for rotator cuff repair come in a variety of materials, all with similar strengths of fixation. Anchors also come in a variety of sizes, mechanisms of fixation, and suture materials. Anchor designs that do not require an arthroscopically tied knot (knotless anchors) are available, but mode of failure and reliability of fixation remain concerns.⁶

Our current preference is a biocomposite anchor, which has the advantages of a biodegradable implant. This anchor is associated with a lower risk of the bone destruction that has been described with the use of the
all-polylactic acid implants. For single-row repairs and the medial row of a double-row repair, we use 5.5-mm anchors double-loaded with high-tensile-strength suture. Lateral-row fixation is accomplished with a knotless anchor to create a linked, double-row construct.

VIDEO 26.1 Arthroscopic Rotator Cuff Repair. Thomas R. Duquin, MD; Donald W. Hohman, MD (30 min)

View Quicktime Video

Video 26.1

Surgical Technique

Performing a successful arthroscopic rotator cuff repair involves 10 steps (Table 1). It is important to complete the steps in sequence.

1. Patient Positioning and Examination Under Anesthesia

Appropriate room setup and patient positioning are essential for successful arthroscopic rotator cuff repair. Having surgical staff members who are experienced in arthroscopic surgery greatly improves the ability to perform all arthroscopic rotator cuff repairs.

Examination under anesthesia is performed on every shoulder before the initiation of surgery. The correlation of preoperative pain and physical examination findings may be corroborated with the examination under anesthesia, and the presence of a joint contracture or instability may alter the course of treatment.

Both the beach-chair position and the lateral decubitus position have been described for rotator cuff repair. Our preference is to place the patient in the beach-chair position with the head of the bed elevated to 80° (Figure 3, A), with careful positioning and wide prep and draping. The surgical arm is placed in an articulated hydraulic arm holder that facilitates exposure.

TABLE 1 Steps in Arthroscopic Rotator Cuff Repair

1. Patient positioning and examination under anesthesia

2. Intra-articular arthroscopy and débridement

3. Subacromial bursectomy and acromioplasty

4. Rotator cuff tear characterization and mobilization

5. Tuberosity and tendon preparation

6. Margin convergence sutures (if required)

7. Anchor placement and suture passage

8. Knot tying

9. Lateral-row repair (if required)

10. Closure and perioperative care

2. Intra-articular Arthroscopy and Débridement

The acromion, distal clavicle, and coracoid process are outlined with a marking pen, and the locations of the standard posterior, anterior, and lateral portals are marked (Figure 3, B, Table 2). The posterior viewing portal (2 cm medial and inferior to the posterolateral corner of the acromion) is established using a blunt trocar, with the arm placed in 15° of abduction and 30° of forward flexion and with the assistant providing a gentle lateral distraction to avoid damage to the articular surfaces. The 30° arthroscope is introduced, and diagnostic arthroscopic examination of the joint is performed.

Thorough diagnostic arthroscopy is performed. A 4.5-mm full-radius shaver is used to perform intra-articular débridement as indicated through an anterior portal. Biceps tendon pathology is treated as indicated with débridement, tenotomy, or tenodesis, depending on the degree of injury and surgeon preference. The initial débridement of the rotator cuff tear is performed with the arthroscope intra-articular. Full-thickness tears allow access to the entire footprint of the tuberosity, which is débrided of all soft tissue using the full-radius resector and radiofrequency ablation wand before moving to the subacromial space.

3. Subacromial Bursectomy and Acromioplasty

After completion of the intra-articular débridement, the arthroscope is moved to the subacromial space. In most symptomatic rotator cuff tendon tears, the bursa is inflamed and thickened, which can compromise visualization. The first landmark to be identified is the coracoacromial ligament. Next, a lateral working portal is created through the deltoid muscle in line with the posterior aspect of the distal clavicle and 2 to 3 cm lateral to the edge of the acromion. A full-radius shaver is used to perform a complete bursectomy. It is important to remove as much bursa as possible to provide adequate space to perform the rotator cuff repair.

The bursa and soft tissue are removed from the undersurface of the acromion using the radiofrequency ablation wand. The anterior aspects of the acromion and coracoacromial ligament are examined. If evidence of impingement is present or if the subacromial space is too small to allow arthroscopic rotator cuff repair, then an acromioplasty is performed.

4. Rotator Cuff Tear Characterization and Mobilization

Following complete bursectomy and acromioplasty, attention is directed to the rotator cuff tendon tear. The importance of visualizing the tear cannot be overemphasized; moving the arthroscope from the posterior portal to the posterolateral portal facilitates inspection. This portal is made 2 cm distal to the posterolateral corner of the acromion. A 7-mm cannula is placed in the posterior
portal and will be used for suture passage and docking. Multiple tear patterns have been described, including crescent-, L-, reverse L-, and U-shaped patterns (Figures 4 and 5). The size of the tear, the degree of retraction, the quality of the tendon tissue, and the excursion of the tendon are important factors in the arthroscopic assessment of a rotator cuff tear. Using a tendon-grasping instrument or placing a traction suture through the lateral portal can be very helpful in assessing the tear pattern and tendon mobility. Within each tear pattern, the mobility of the tear must be assessed, and soft-tissue releases may be required to attain reduction of the tendon to the tuberosity before the initiation of repair. Tension-free repair may require the evaluation and dissection of both the bursal and articular side of the tendon. Specifically, the tear pattern, chronicity, degree of retraction, and mobility of the tendon may warrant the release of adhesions on both sides of the tendon. This also may include
the release of the rotator interval, thereby increasing tendon excursion. These maneuvers may be performed effectively with either electrocautery or a tissue elevator. Coracohumeral ligament release (interval slide) from a retracted supraspinatus tendon is simple in principle and can significantly enhance the mobility of a retracted rotator cuff tear.

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