Arthroscopic Rotator Cuff Repair: Single-Row Technique

Chapter 20


Arthroscopic Rotator Cuff Repair


Single-Row Technique








Although the use of arthroscopic techniques for operative repair of the rotator cuff has become increasingly common, controversy has emerged between advocates of single-row anchor fixation and those who advise use of two such rows (e.g., “double row,” “dual row,” “suture bridge,” “transosseous equivalent”). Proponents of single-row fixation cite decreased cost and decreased operative time and point out the dearth of clinical outcome studies that justify use of double-row techniques. Proponents of double-row fixation, on the other hand, cite biomechanical advantages that include superior repair strength1 and footprint coverage,2 decreased micromotion at the tendon-bone interface,3 and increased, more homogenous pressure distribution across the repair site.4 All of these factors, they suggest, may translate into improved healing potential at the tendon-bone interface. More recently, arthroscopic non–anchor-based transosseous techniques have been developed and may hold significant promise, but for the time being they remain out of mainstream practice.


Although investigations continue to pursue an answer to the question, “Is more better?” with respect to fixation, the use of single-row fixation remains an acceptable and in most cases less technically challenging arthroscopic repair technique for repair of the rotator cuff. Furthermore, given certain time-tested principles of rotator cuff repair, such as minimization of tension at the repair site, larger L-shaped, reverse-L–shaped, and U-shaped tears may be better suited to a single-row approach, particularly if they are chronic or acute-on-chronic with limited mobility, as efforts toward “anatomic” footprint coverage may result in excessive repair tension. Finally, regardless of the technique used for repair, the need for recognition of tear size and pattern, execution of necessary mobilization procedures including interval slides when indicated, appropriate footprint preparation, effective suture management, and appropriate rehabilitation remain essential elements of any properly performed arthroscopic rotator cuff repair.



Preoperative Considerations






Imaging




• Plain radiographs consisting of Grashey, outlet, and axillary views for the following:



– Evidence of greater tuberosity fracture when a history of trauma is present.


– Acromial morphology including identification of enthesophyte on outlet view and os acromiale on axillary view.


– Presence of static superior migration of the humeral head with respect to the glenoid. Note that the presence of such static changes together with a large or massive tear serves as a relative contraindication to operative repair. Superior static migration is the condition to look for on plain radiographs. Presence of a massive tear is inferred from the presence of observable static migration.


– Presence of degenerative, chronic changes such as osteophyte formation along the inferior anatomic neck of the humeral head, acetabularization of the undersurface of the acromion, sclerosis and “rounding off” of the greater tuberosity, narrowing of the glenohumeral joint space, and loss of sphericity of the humeral head.


• Magnetic resonance imaging (MRI) for the following:



– Identification of tear size, degree of retraction, tendon quality, and presence of intratendinous delamination and potentially recognition of tear pattern (Fig. 20-1).



– Quantification of associated muscle belly atrophy and fatty infiltration. Note this is best performed on T1-weighted sagittal oblique views at the first cut in which the scapular spine becomes visible and can be useful in determining the reparability of the tear.


– Identification of associated, potentially surgical pathology such as acromioclavicular arthritis or osteolysis, partial-thickness tearing or subluxation of the long head of the biceps tendon, articular cartilage defects, labral pathology, calcific tendonitis, intra-articular loose bodies, and subscapularis pathology.


• Ultrasonography





Indications and Contraindications





Surgical Technique



Anesthesia and Positioning


The surgeon should base anesthetic choice on consideration of patient preference, medical comorbidities (e.g., presence of morbid obesity or chronic obstructive pulmonary disease (COPD) may increase risk of respiratory compromise with interscalene regional block should the long thoracic nerve be affected), and skill of the anesthesiologist, but some combination of endotracheal, laryngeal mask airway, and regional anesthesia will typically be used.


Use of regional anesthesia such as an interscalene block with an indwelling catheter offers the patient effective pain control in the outpatient setting by extending the analgesic effects of the block for several days postoperatively. This can potentially reduce a patient’s need for postoperative narcotic pain medication and thereby diminish the risk of associated side effects such as nausea, constipation, urinary retention, and narcosis.


Positioning may be either beach chair or lateral decubitus, depending on surgeon preference. However, beach chair positioning permits the surgeon to manipulate the humerus freely to improve arthroscopic access to the greater tuberosity, particularly during anchor placement.


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Sep 11, 2016 | Posted by in SPORT MEDICINE | Comments Off on Arthroscopic Rotator Cuff Repair: Single-Row Technique

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