Arthroscopic Rotator Cuff Repair: Single-Row Repair (Classic)


Chapter 19

Arthroscopic Rotator Cuff Repair


Single-Row Repair (Classic)



Fabian Plachel, Philipp Moroder, and Markus Scheibel

Introduction


Although arthroscopic rotator cuff repair has largely replaced traditional open surgery for the treatment of a symptomatic full-thickness rotator cuff tear, the optimal repair technique is still a matter of debate. Although the modern double-row repair techniques have been recommended to increase the coverage of the tendon–bone junction and thus enhance healing of the tendon–bone interface, a superior method regarding the clinical outcome and the retear rate has yet to be found. As suture cut-through is a major concern, especially with the single-row repair techniques applied in cases with poor tendon quality, the self-locking modified Mason-Allen suture grasping technique has become effective for arthroscopic usage (Fig. 19.1). This modified repair technique is reported to be biomechanically superior to other single-row techniques and as stable as double-row configurations. At the same time, it is believed to reduce the risk of tendon strangulation compared with the double-row repair. Finally, this technique for single-row suture anchor repair is a more cost-effective repair technique than the double-row technique. We prefer using the modified Mason-Allen suture grasping technique in small superior or posterosuperior crescent-shaped rotator cuff tears.

Procedure



Patient History



Patient Examination





  1. • The clinical examination should always include inspection and palpation, assessment of active and passive range of motion and strength, as well as functional shoulder testing. Remember to compare the affected extremity with the nonaffected extremity.
  2. • Atrophy of the supraspinatus or infraspinatus could suggest a chronic rotator cuff tear.
  3. • Isolated limitation on active range of motion is due to either true weakness or weakness caused by pain. Passive range of motion is mostly preserved and not necessarily painful.
  4. • Rotator cuff strength, including resisted elevation and external and internal rotation, should be evaluated with manual muscle testing. A loss of strength is best determined when compared with the nonaffected shoulder.
  5. • Functional shoulder testing allows for a more specific diagnosis. We prefer the empty can and full can test to evaluate the supraspinatus muscle (Fig. 19.3). If positive, a tear of the supraspinatus tendon is suspected. Involvement of the infraspinatus tendon should be evaluated using the external rotation resistance test along with the external rotation lag sign (Fig. 19.4). A positive hornblower’s sign may indicate additional teres minor dysfunction.

  6. image
    FIG. 19.1 The single-row rotator cuff repair using the modified Mason-Allen suture-grasping technique: once the sutures are passed through the tendon creating a horizontal mattress stitch with a perpendicularly overlying simple stitch, the sutures are tied starting with the mattress stitch. 
    Scheibel MT, Habermeyer P. A modified Mason-Allen technique for rotator cuff repair using suture anchors. Arthroscopy. 2003;19:330–333.     Fig. 2, p. 332.

  7. • Use as few examinations as necessary, but as many as needed, to reveal the correct diagnosis.

Imaging





  1. • Conventional radiography is the first method of imaging in patients with shoulder disorders. In the case of a small full-thickness rotator cuff tear, radiography may not reveal anything abnormal. An excessive lateral extent of the acromion defined by either the acromion index (Fig. 19.5) or the critical shoulder angle (Fig. 19.6) on the anteroposterior view may predict a rotator cuff tear. An upward migration of the humeral head combined with osseous changes of the greater tuberosity and the inferior surface of the acromion may reveal tear chronicity and size.

  2. image
    FIG. 19.2 The modified Mason-Allen suture-grasping technique is composed of a horizontal mattress stitch and a vertical simple stitch in order to improve the tissue-holding power of the construct and to increase the contact area of the tendon–bone interface. 
    Scheibel MT, Habermeyer P. A modified Mason-Allen technique for rotator cuff repair using suture anchors. Arthroscopy. 2003;19:330–333.     Fig. 3, p. 332.

  3. • Ultrasound is a valuable tool to dynamically assess the rotator cuff. Although sensitivity and specificity are high in diagnosing a full-thickness cuff tear, the accuracy is strongly user-dependent. The tear is distinctively marked by tendon volume loss and focal nonvisualization with fluid-filled spaces (Fig. 19.7).
  4. • The gold standard in diagnosing a rotator cuff tear is magnetic resonance imaging. Both tendon and muscle quality may be evaluated, which helps improve preoperative planning. The reparability of the tendon is assessed by evaluating tear size, tendon retraction, fatty infiltration, and atrophy of the muscle (Fig. 19.8).
  5. • Computed tomography arthrography can be used for evaluation of the rotator cuff in patients with a pacemaker or claustrophobia. A benefit is the direct assessment of bone quality, which is useful in the elderly.


image
FIG. 19.3 (A) Empty can test: both arms are elevated to 90 degrees in the scapular plane (30 degrees of horizontal adduction), as well as fully internal rotated. The patient resists downward pressure exerted by the examiner. The posterior part of the supraspinatus tendon is tested. (B) Full can test: both arms are now fully external rotated to test the anterior part of the supraspinatus tendon. 
Irlenbusch U. Untersuchungstechniken des Schultergelenks. Obere Extremität. 2012;7:3-68. Original figures: Abb.3 8 Empty-Can-Test, Abb.39: Full-Can-Test, p. 37.

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FIG. 19.4 External rotation resistance test: with both arms in neutral position and elbows flexed at 90 degrees, the patient rotates the shoulder externally against the resistance of the examiner. 
Irlenbusch U. Untersuchungstechniken des Schultergelenks. Obere Extremität, 2012;7:3-68. Original figure: Abb. 5 Außenrotationstes (AR-Test) bei 0° Abduktion (Infraspinatus), p. 12.

image
FIG. 19.5 The acromion index is measured on a true anteroposterior radiograph. The distance between the glenoid plane and the lateral aspect of the acromion (GA) is divided by the distance between the glenoid plane and the lateral border of the proximal humerus (GH).

image
FIG. 19.6 The critical shoulder angle is determined on a true anteroposterior radiograph by measuring the angle between the glenoid plane and the lateral aspect of the acromion.

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FIG. 19.7 T2-weighted coronal magnetic resonance imaging showing a full-thickness tear of the supraspinatus tendon. The tendon integrity is interrupted close to the greater tuberosity resulting in a space filled by fluid.

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FIG. 19.8 T1-weighted sagittal magnetic resonance imaging is used to accurately assess the muscle quality by determining the fatty infiltration and atrophy.

Treatment Options



Surgical Anatomy



Surgical Indications



Related posts:

Patient Positioning and Anesthesia for Rotator Cuff Surgery Arthroscopic Trillat Procedure for Recurrent Anterior Shoulder Instability With Associated Irreparable Rotator Cuff Tear Nonoperative Care of Rotator Cuff Disorders: Physical Therapy, Modalities, and Injectables What Type of Rotator Cuff Tear Is This? Tear Pattern Recognition and Soft-Tissue Releases Impingement Syndrome: Diagnosis and Management Shoulder Stiffness (Adhesive Capsulitis) With A Rotator Cuff Tear: How to Manage

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Mar 28, 2020 | Posted by in ORTHOPEDIC | Comments Off on Arthroscopic Rotator Cuff Repair: Single-Row Repair (Classic)

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