Transitioning From Open to Arthroscopic Rotator Cuff Repair: Pearls for Success


Chapter 14

Transitioning From Open to Arthroscopic Rotator Cuff Repair


Pearls for Success



Abdullah Foad, and George Sanchez

Introduction


The goal of any rotator cuff repair technique is to relieve pain, improve strength, increase range of motion, and restore function. An arthroscopic rotator cuff repair can be demanding and requires a sound understanding of biomechanics and tear patterns as well as attention to details. Yet, the credibility of the arthroscopic technique for rotator cuff repair has advanced so dramatically over the past two decades that it is now considered to be the new “gold standard” by most shoulder surgeons in the developed world. The evolution and increase in popularity of the arthroscopic technique has paralleled modern advancements in arthroscopic technology, fixation methods, instrumentation, and surgeon experience.

Procedure





  1. • The positive long-term outcomes of arthroscopic rotator cuff repairs have been well documented in the literature and are equivalent to or better than outcomes associated with mini-open repair techniques.
  2. • Arthroscopic rotator cuff repairs display good to excellent outcomes in 90% of cases, with 85% to 95% of patients having improved pain and restoration of function.
  3. • These favorable results were seen not only in short-term follow-ups but also in long-term follow-up beyond 5 years.
  4. • The arthroscopic technique also provides exclusive advantages not possible in the open and mini-open repair techniques, including an ability to evaluate and treat concomitant intraarticular pathology and to provide better evaluation of tear patterns, better visualization of larger tears, and reduced morbidity and postoperative stiffness.


    1. • In particular, one randomized, prospective, controlled trial showed earlier return of motion in the first 12 weeks, although the authors reported that the final outcome was not clinically significant. This may be due to less soft tissue and deltoid dissection, leading to less initial postoperative pain and stiffness.

  6. • An arthroscopic cuff repair can be as successful and predictable for large tears as for small- and medium-sized tears, with possibly more biomechanical benefit than the open technique.
  7. • The arthroscopic technique provides better visualization of subscapularis and posterior cuff tears. It is imperative to repair the subscapularis and infraspinatus tendons in order to restore balanced force couples (Figs. 14.1 and 14.2). In contrast, the open technique may provide limited visualization and force the surgeon to think only in a mediolateral direction.
  8. • In massive, chronically retracted tears, the arthroscopic technique may be the only method to obtain a successful repair.


image
FIG. 14.1 Schematic illustration of a right shoulder demonstrating a subscapularis tendon tear left unrepaired. (A) Both the subscapularis and posterosuperior tendons are torn. (B) The subscapularis has been left unrepaired while the posterosuperior tendons have been repaired. There will be loss of the anterior cable attachment, thus producing additional strain that can lead to failure of the repaired posterosuperior tendons. 
From Ticker, JB, Burkhart, SS. Why repair the subscapularis? A logical rationale. Arthroscopy. 2011;27:1123–1128, Fig. 2.

image
FIG. 14.2 Schematic illustration, demonstrated in (A) and (B), of a right shoulder demonstrating the repair of the anterior cable attachment. This links the supraspinatus and subscapularis tendons together, thus restoring balanced force couples and not only restoring the function of the subscapularis but also facilitating and reducing the strain on the repaired posterosuperior rotator cuff tendons. 
From Ticker, JB, Burkhart, SS. Why repair the subscapularis? A logical rationale. Arthroscopy. 2011;27:1123–1128, Fig. 4.

Strategies for Transitioning


With advances in arthroscopic techniques and instrumentation, the learning curve for an all-arthroscopic rotator cuff repair has been and continues to be gradually shortened. A direct leap to an all-arthroscopic rotator cuff repair may be inappropriate and frustrating for the inexperienced surgeon (especially concurrent with an inexperienced team), with added risk for otherwise avoidable complications. A candid discussion regarding the possibility of converting to an open or a mini-open repair should be held with the patient before surgery. It is important to recognize that success and patient satisfaction rates in rotator cuff surgery are higher in patients with intact repairs.

The traditional mini-open technique is a logical approach to transitioning in a systematic and incremental fashion while circumnavigating issues regarding deltoid takedown. The transitioning surgeon should work at his or her pace and comfort level, not become frustrated or overwhelmed, and have a low threshold for converting to a mini-open repair (Fig. 14.3). Multiple studies have shown good to excellent outcomes with the mini-open technique.

The surgeon can begin with simple arthroscopic subacromial decompression and gain experience with visualization, control of bleeding, and removal of the subacromial bursal veil that covers the rotator cuff tendon when transitioning to the all-arthroscopic technique. The next step in the transition may include debridement of tendon edges, recognition of tear patterns, and lysis of adhesions from both the articular surface (superior to the glenoid labrum) and the bursal surface (bursal leaders). At a more advanced level, release of adhesions at the base of the coracoid with mobilization of the superior glenohumeral and coracohumeral ligament complex may need to be done. However, this is performed for large or massive retracted tears. The first author recommends that the transitioning surgeon begin with a small (1–2 cm in length) single-tendon (supraspinatus), nonretracted, mobile, crescent-shaped tear (Fig. 14.4).

image
FIG. 14.3 Intraoperative photograph of a right shoulder demonstrating a mini-open rotator cuff repair. 
From Petri M, Warth RJ, Horan MP, et al. Outcomes After Open Revision Repair of Massive Rotator Cuff Tears With Biologic Patch Augmentation. Arthroscopy. 2016;32(9):1752–1760.

The subsequent step in the transition involves placing sutures through the tendon to assess mobility. If difficulties are encountered in this step, one can convert to the mini-open approach by extending the portal 2–3 cm to gain access for a stable tendon–bone fixation. With more experience, sutures can be incorporated with the suture anchors. At the same time, the greater tuberosity footprint is prepared, and bone tunnels are made for anatomic placement of the anchors.

image
FIG. 14.4 Arthroscopic view of a left shoulder. (A) View from an anterosuperolateral subacromial portal of a small, nonretracted, mobile, crescent-shaped, single-tendon rotator cuff tear. (B) View from a lateral subacromial portal demonstrating a simple single row rotator cuff tendon repair. (C) View from a posterior glenohumeral portal demonstrating an anatomic restoration of the articular surface of the rotator cuff to its footprint.

Surgical Technique Setup


Positioning



Equipment




Cannulas



70-Degree Scope





  1. • Both 30- and 70-degree arthroscopes are useful.
  2. • Gain familiarity with the 70-degree arthroscope in the subacromial space.
  3. • The 70-degree scope provides an acute angle to allow the surgeon to “look around the corner” (Fig. 14.8).
  4. • Can be useful for the small anterior supraspinatus tears (often less than or equal to 1 cm) while viewing through a posterior portal by allowing one to obtain an excellent view of the footprint for preparation and anchor placement.


  5. TABLE 14.1
















































    Advantages and Disadvantages of the Lateral Decubitus and Beach Chair Positions for Arthroscopic or Open Shoulder Surgery
    Position Advantages Disadvantages
    Lateral decubitus Traction increases space in the glenohumeral joint and subacromial space Nonanatomic orientation (i.e., glenoid is parallel to the floor)
    Traction accentuates labral tears Must reach around arm for anterior portal
    Operating room table and/or patient’s head not in the way of posterior and superior shoulder May need to reposition and redrape to convert to open procedure
    Cautery bubbles move laterally out of view Not ideal for patients who cannot tolerate regional anesthesia
    No increased risk of hypotension/bradycardia Traction can cause neurovascular and soft-tissue injury

    		Better cerebral perfusion Increased risk of injury to axillary and musculocutaneous nerves when placing anteroinferior portal
    Beach chair Upright, anatomic position Potential mechanical blocks (e.g., the head) to the use of arthroscope in posterior or superior portals
    Ease of examination under anesthesia and ability to stabilize the scapula Increased risk of hypotension/bradycardia causing cardiovascular complications (i.e., cerebral ischemia)
    Arm not in the way of anterior portal Cautery bubbles obscure view in the subacromial space
    No need to reposition or redrape to covert to open procedure Fluid can fog camera if there is a leak in the attachment or in certain cameras
    Can use regional anesthesia with sedation Theoretically increased risk of air embolus/pneumothorax
    Mobility of surgical arm and ability to set up arm holder to the operating room table Expensive equipment if using beach chair attachment with or without mechanical arm holder


    image


    From Li X, Eichinger JK, Hartshorn T, et al. A comparison of the lateral decubitus and beach-chair positions for shoulder surgery: Advantages and complications. J Am Acad Orthop Surg. 2015;23:18–28.




  6. TABLE 14.2






















    Prevention of Position-Related Complications During Shoulder Arthroscopy
    Beach chair Lateral decubitus
    Reference systolic pressures at level of brain Use of safe shoulder positions when arm is placed in traction
    Attentive care to intraoperative head positioning 45 degrees of forward flexion with 90 degrees of abduction
    Consider use of hypotensive bradycardic episode prophylactic measure when using interscalene block 45 degrees of forward flexion with 0 degrees of abduction
    Proper padding of the common peroneal nerves Placement of anterior inferior portal out of traction


    Consider use of general anesthesia for longer cases

    Proper padding of the common peroneal nerves

    From Rains DD, Rooke GA, Wohl CJ. Pathomechanisms and complications related to patient positioning and anesthesia during shoulder arthroscopy. Arthroscopy. 2011;27:532–541.


  7. • It is particularly useful for more advanced procedures such as subscapularis tendon release and repair, subcoracoid decompression, and double-interval slides.
  8. • 4.5-mm arthroscopic shaver and a 90-degree radiofrequency device to debride bursal tissue, maintain hemostasis, and improve mobilization of the arthroscope and instruments.
  9. • Arthroscopic burrs and ringed curettes are useful for footprint preparation by allowing for light decortication and clearance of the articular margin for procedures such as a transtendon rotator cuff double-row double-pulley repair for partial articular surface tendon avulsion (PASTA) lesions) that are greater than 50% of the tendon width (Fig. 14.9).
  10. • An arthroscopic microfracture instrument can be used to promote a bleeding bone bed and create a nidus for entry of growth factors and blood marrow products (crimson duvet as described by Stephen J. Snyder, MD) (Fig. 14.10).


Suture-Passing Instruments



Retrograde Devices



Antegrade Devices



Shuttling Devices



Anchors/Sutures





  1. • Anchors vary significantly in size, shape, composition, and insertion technique.

  2. image
    FIG. 14.8 Arthroscopic view of a left shoulder from a posterior glenohumeral portal demonstrating visualization of the subscapularis tendon footprint with (A) a 30-degree arthroscope and (B) a 70-degree arthroscope to “look around the corner” for better appreciation of a tear.


  4. • One should become familiar with the steps necessary for anchor placement for each device used.
  5. • Choose anchors that have sufficient pullout strength and suture cutout: those that are double- or triple-loaded or can accept at least two sutures to maximize footprint restoration.
  6. • Consider threaded screw-in anchors.
  7. • Choose anchors that are strong enough for in vivo forces and cause minimal suture abrasion.
  8. • Suture characteristics should include being nonabsorbable, thereby minimizing the effect of suture abrasion and allowing for ease of knot-tying.
  9. • For the last two decades, metal anchors were the mainstay. More recently, nonmetallic anchors (e.g., polyglycolic acid, poly-L-lactic acid, polyether ether ketone, tricalcium phosphate, and hydroxyapatite) are being used due to capability of bone integration and ease of revision, if necessary.
  10. • Knotless suture anchors are also available and should have the same characteristics.


image
FIG. 14.9 Arthroscopic view of a right shoulder from a posterior glenohumeral portal using a 70-degree arthroscope demonstrating (A) a partial articular surface tendon avulsion lesion, (B) preparation with light decortication of the exposed footprint with a combination of arthroscopic burr and ringed curettes (double-headed arrow demonstrates the exposed and prepared footprint of the rotator cuff), and (C) arthroscopic view from a posterior subacromial portal of a transtendon rotator cuff double-row, double-pulley repair.

image
FIG. 14.10 (A) and (B) Arthroscopic views of a right shoulder from a lateral portal demonstrating microfracture technique into the prepared bone bed in patients who have lower healing potential to allow bone marrow products to extrude into the repaired rotator cuff site.

image
FIG. 14.11 (A) Arthroscopic view of a left shoulder demonstrating a delaminated tear that would be amenable to using a retrograde device for suture passage to help with providing equal tension of both muscle-tendon layers. (B) The Banana Lasso (Arthrex, Inc., Naples, FL) retrograde suture-passing device.

Knot Pusher



Surgical Exposure/Portals


Visualization





  1. • In order to successfully transition to all-arthroscopic rotator cuff repairs in an effective and time-efficient manner, the surgeon must adapt from a three-dimensional operative field to a two-dimensional arthroscopic screen. To begin this process, one needs to obtain adequate visualization.


  3. image
    FIG. 14.12 Schematic illustration of the tension mismatch created in the muscle-tendon segments of the supraspinatus if retrograde suture passage is used through a modified Neviaser portal. (A) Retrograde suture passage is performed through a modified Neviaser portal. (B) The suture has been passed through the rotator cuff obliquely. (C) Tying the suture results in a tension mismatch as the superior surface of the rotator cuff is pulled farther lateral than the inferior surface. 
    Courtesy Burkhart SS, Lo IKY, Brady PC, Denard PJ. The Cowboy’s Companion: A Trail Guide for the Arthroscopic Shoulder Surgeon. Philadelphia: Lippincott Williams & Wilkins; 2012.

  4. • Bleeding commonly occurs in the subacromial space.
  5. • Hypotensive anesthesia can be beneficial, but the beach chair position can carry a risk for cerebral and spinal cord hypoperfusion.
  6. • A 90-degree electrothermal wand is useful in short bursts to control bleeding and fluid temperature.
  7. • Avoidance of bleeding vessels in the subacromial space:


    1. • The acromial branch of the thoracoacromial trunk underneath the anterior coracoacromial (CA) ligament.
    2. • Medial subacromial bursa overlying the rotator cuff muscle-tendon junction




  11. image
    FIG. 14.13 (A) The Scorpion FastPass (Arthrex, Inc., Naples, FL) antegrade suture-passing device. (B) Close-up view demonstrating jaws closed and penetration of the suture by the nitinol needle.

    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 Subscapularis Tendon Tears: Arthroscopic Management Arthroscopic Rotator Cuff Repair: Double Row

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Mar 28, 2020 | Posted by in ORTHOPEDIC | Comments Off on Transitioning From Open to Arthroscopic Rotator Cuff Repair: Pearls for Success

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