Setup

All patients undergoing an arthroscopic rotator cuff repair in our facility have an interscalene block. This regional anesthesia is administered by the anesthesia staff at least 30 minutes prior to the case. The block uses long-acting local anesthetics and steroid, which enhances its longevity, providing upward of 24 to 36 hours of analgesia. Most patients have a concomitant general anesthetic to provide hypotensive anesthesia for enhanced visualization during arthroscopy. In the past, selective criteria were used to determine who best should have additional general anesthesia; however, I have found that the hypotension provided with the general anesthetic improves visualization greatly and is thought to be of such low risk to the patient because of the lesser amount of anesthetic agent needed when used with a block. Thus, I routinely use a block augmented with general anesthesia. Those patients with pulmonary compromise are excluded from having a block because of the risk of phrenic nerve palsy and respiratory compromise.

All cases are performed with the patient in the lateral decubitus position, allowing ready access to the posterior, anterior, and superior aspects of the shoulder while holding the arm in a position of slight abduction, thereby facilitating approximation of the free tendon edge to the region of the greater tuberosity (Fig. 20-1). The arm is rotated as needed to optimize anchor placement and reduce tension during suture tying. In most patients, 10 pounds of traction at approximately 30 to 40 degrees of abduction is more than adequate to provide the proper shoulder position. Anesthesia is moved out of the immediate operative field to allow unimpeded access to the entire shoulder region.

FIGURE 20-1 Patient in lateral decubitus position, with arm abducted 40 degrees.

Every procedure begins with a basic set of instruments, including a simple knot pusher, ring grabber or crab claw device for retrieving individual sutures, set of cannulated suture passers, cannula for fluid management, and various suture retrievers (Fig. 20-2). Additional instruments can be added as neededs.

FIGURE 20-2 Basic set of instruments, including knot pusher, Liberator knife (Conmed Linvatec, Largo, Fla), ring grasper, punch baskets, and suture retriever.

Portals

All arthroscopic repairs require three principal portals and an additional ancillary anterior portal. The viewing portal is located 1 cm medial and 2 cm inferior to the posterolateral corner of the acromion (Fig. 20-3). The arthroscopic subacromial decompression (ASD) instrument portal is located immediately anterior to the finish line, a line drawn perpendicular to the lateral margin of the acromion, beginning at the posterior extent of the acromioclavicular joint and 2 to 3cm lateral to the lateral margin of the acromion. The anchor portal location is determined during subacromial viewing using the needle localization technique; it is typically at the anterolateral corner of the acromion. An additional fourth portal may be made anterior to the acromion, called the waiting room portal. I use this for large tears in which three or more anchors and six or more sutures are involved. This portal allows me to dock sutures that are not being worked with anteriorly to free up the viewing area while posterior sutures are tied. This aids greatly in suture management.

FIGURE 20-3 The patient is in the lateral decubitus position, with the right shoulder exposed. The viewing portal is located 1 cm medial and 2 cm inferior to the posterolateral corner of the acromion. The ASD instrument portal is located anterior to the finish line and 2 to 3cm inferior to the lateral margin of the acromion. The anchor portal is at the anterolateral corner of the acromion. The waiting room portal is made just off the anterior edge of the acromion.

Once the need for a repair has been determined, all portals are secured with cannula. The size of the cannula is dependent on the anticipated use of that portal. For example, the posterior portal is often used also for instrument access with the Spectrum (Conmed Linvatec, Largo, Fla) cannulated suture passer. This device requires at least an 8-mm opening and thus an 8-mm cannula. The anchor portal, however, is used almost exclusively for anchor insertion and knot tying, so a smaller 5-mm cannula is adequate. The lateral, or instrument portal, is sized according the instrument to be used for that repair. In most cases, and with most instruments, a 6- to 7-mm cannula is acceptable. Use of a cannula greatly diminishes fluid extravasation into the soft tissue, minimizes overall fluid requirements, and enhances visualization by maintaining hydrostatic pressure in the subacromial space. Cannulas also allow the surgeon to move the scope freely from portal to portal to improve visualization and prevent soft tissue from being entangled with sutures during passage and tying.

Glenohumeral Inspection

All shoulder procedures, whether they are ARCR, instability, or ASD, begin with a thorough inspection of the glenohumeral joint to identify and treat other associated pathology, such as superior labrum anteroposterior (SLAP) lesions, capsulolabral disruptions, biceps tears, and loose bodies. Partial-thickness tears of the rotator cuff can be assessed, localization sutures placed and, if a high-grade lesion is encountered, a formal débridement of the lesion with conversion to a full-thickness tear or a transtendinous repair may be performed, preserving the intact bursal fibers. If a large, fixed, retracted tear is encountered, this is the optimal time to begin the capsulotomies and releases.

Acromioplasty

Although there has been debate regarding the need and efficacy of ASD in ARCR,^17–19 an acromioplasty allows for enhanced visualization during the repair and increased room for instrumentation, and lessens the likelihood of later impingement of the repaired cuff. The ASD should require no more than 10 to 15 minutes to complete. To that end, in all chronic and many acute full thickness rotator cuff tears, I routinely perform a concomitant ASD. Viewing from the posterior portal, a bursectomy is performed to visualize the inferior surface of the acromion. If a large rotator cuff tear has been identified, the bursectomy is carried around the anterior, lateral, and posterior gutters to improve visualization and facilitate instrumentation of the subscapularis and/or infraspinatus tendons. When the bursectomy is complete, a radiofrequency (RF) device removes all residual soft tissue from the under surface of the acromion and releases the coracoacromial (CA) ligament from its attachment on the anteroinferior aspect of the acromion (Fig. 20-4). This is only a CA ligament release, not a resection. The burr is introduced from the lateral portal and the decompression begun at the anterolateral corner, working both medial and posterior (Fig. 20-5). An adequate decompression is achieved when the acromioplasty is tapered and terminates at or about the finish line (the line drawn at the time of initial portal placement; see earlier). Finally, the decompression is completed by moving the arthroscope to the lateral portal, bringing the burr in from the posterior portal and finished with a cutting block technique.

FIGURE 20-4 View from the posterior portal of a right shoulder using a 30-degree arthroscope rotated 90 degrees toward the patient’s head (the acromion is at the top of this ilustration). An RF device is introduced through the lateral portal to remove residual soft tissue from the inferior surface of acromion and release the coracoacromial ligament in preparation for the acromioplasty.

FIGURE 20-5 Viewed from the posterior portal of this right shoulder, a burr is introduced from the lateral portal and the decompression is begun, starting at the anterolateral corner of the acromion, removing bone in medial and posterior directions.

Mobilization and Tear Pattern Recognition

Many chronic, long-standing rotator cuff tears present with retracted margins, are adherent to the surrounding soft tissue, and require some sort of mobilization to facilitate a tension-free repair. There are four basic types of releases used in ARCRs—subacromial, paralabral capsulotomies, and anterior and posterior interval releases. The subacromial release is performed with traction sutures applied to the tendon edge while using a shaver or small periosteal elevator to tease the adherent tendon from the undersurface of the acromion. Paralabral capsulotomies are used in cases of significant medial retraction and/or thickened scarred capsule and are best performed at the time of glenohumeral inspection using a basket or RF device through an anterior portal to release the capsule selectively, just outside the labral margin. Anterior and posterior interval releases are used when there has been an asymmetrical medialization retraction of the supraspinatus or infraspinatus, as seen in L-shaped and reverse L-shaped tears.²⁰ However, these are seldom needed for smaller, less retracted tears.

During the assessment of tendon mobility, the surgeon determines the tear pattern and plan for the repair. The critical consideration in all lesions is where the tendon edges are now and where they were when the tear originated. Based on the answers, and having done a dynamic assessment of mobility, releases can be performed and the repair planned so as to minimize tension at the repair site, thereby optimizing the outcome.

Anchor Placement

With the acromioplasty complete, the tendon edges mobilized, and the repair planned, anchors are placed in a position that affords minimal tension on the tendon margin at repair. Prior to anchor insertion, the greater tuberosity and footprint of the tendon are prepared by removing all interposed soft tissue, which could compromise healing, and lightly decorticating the bony surface. The intent of the footprint preparation is to create a stimulus for fibroblastic proliferation and enhanced tissue healing. Anchor choice is dependent on the surgeon’s preference; however, almost all current ARCR anchors are double- or triple-loaded with a strong nonabsorbable suture material and have good pullout strength. In addition to metal anchors, most manufacturers provide devices made of PEEK material with pullout strength comparable to metallic anchors, yet without the artifact that the metal anchors generate in postrepair MRI imaging.

Increasingly, the recommendation has been for the use of DR repairs. Proponents argue that there are enhanced initial stability and repair construct fixation, with the anticipation of a lower retear rate postoperatively.^21–28 If the tear is smaller and mobile, readily approximated to the tuberosity, a single-row (SR) repair can be used. In such cases, anchor placement will be at or just medial to the lateral margin of the greater tuberosity (Fig. 20-6). In larger tears, when a DR repair is desired, medial anchors are placed 5 mm lateral to the articular margin and lateral anchors at the greater tuberosity or just lateral to it (Fig. 20-7). After each anchor is placed, traction is applied to the sutures to verify anchor stability.

FIGURE 20-6 Viewed from the posterior portal in a left shoulder, a metallic anchor is introduced through the anterolateral anchor portal along the medial wall of the greater tuberosity in preparation for a single-row repair.

FIGURE 20-7 In this right shoulder, viewed from the posterior portal, a PEEK anchor is placed 5 mm off the margin of the articular surface as the first anchor of the medial row in a double-row repair.

Suture Passing

As arthroscopic rotator cuff repair has evolved, so have the different techniques for suture passing. Early methods required the surgeon to pass the preloaded anchor through the tendon, anchor and all. Alternatively, the surgeon could pass the sutures through the tendon first and then load them on to the anchor, insert the anchor, and tie the sutures. Newer techniques and passing devices allow for initial anchor placement followed by suture passing via a number of different methods, each of which requires a specific instrument and skill set for its completion.

Antegrade Passers

These devices have in common the ability to couple one limb of an anchor suture to its flexible needle, grasp the tendon edge, and drive the needle, with suture, through the tendon, where it is retrieved with a grasper. The advantages inherent in these instruments include the substantial depth of their bite from the tendon margin and reusability from case to case, with only needle replacement required. The technique begins with anchor placement, medially if a double row or laterally if a single row. While viewing from the posterior portal, individual sutures are retrieved from the anterior anchor portal and moved to the lateral portal, where they are loaded into the passer. The passer is introduced through the lateral portal into the subacromial space, the jaws are opened, and the passer is advanced medially to optimize tissue purchase (Fig. 20-8). Next, the jaws are closed and the needle, with suture attached, is driven from the articular to bursal surface of the tendon and retracted, leaving the suture loop on the bursal surface for retrieval (Fig. 20-9). If a DR repair is being performed, both limbs of each of the two anchor sutures are passed, creating a horizontal mattress stitch. The passed suture limbs are moved out of the immediate work area to the waiting room portal anteriorly and the process begins again with the next anchor.

FIGURE 20-8 Viewed from the posterior portal of a right shoulder, an antegrade suture passer is introduced through the lateral portal into the subacromial space, the jaws are opened, and the passer is advanced medially to optimize tissue capture.

FIGURE 20-9 The device’s jaws are closed and the needle is driven from the articular surface of the tendon to the bursal surface, delivering the suture loop to the bursal surface for retrieval.

Retrograde Snare Technique

In this technique, viewing is done from the lateral portal. With anchors in place, the retrieval device is introduced from the posterior, waiting room, or anteromedial portal based on tear pattern. Most of these retrograde retrieval devices allow the surgeon to penetrate the tendon edge 1 to 2 cm medial to its lateral margin (Fig. 20-10). Once through the tendon, the snare is opened and an individual suture limb is grasped (Fig. 20-11). The snare is closed only enough to retain the suture but not so much as to impede its motion through the snare eyelet. The retriever is withdrawn, bringing the suture limb along and creating a simple suture pass through the tendon ready for tying. This process is repeated for all suture limbs of each double-loaded anchor.

FIGURE 20-10 Viewed from the edge of the rotator cuff tendon, the arthroscope is in the lateral portal. The retrograde snare has been passed through the tendon edge in preparation for capturing an anchor suture.

FIGURE 20-11 Once through the tendon, the snare is deployed, the suture grasped, and the snare retracted for removal.

Pulling Stitches or Suture Shuttles

There are a number of commercially available devices that allow the passage of a monofilament suture or a shuttle device. In both scenarios, the instrument penetrates the tendon on the articular or bursal surface of the tendon (Fig. 20-12) and deploys the suture or retrieval loop once it is through the tendon, where it is grasped and brought out a separate portal (Fig. 20-13). One limb of the anchor suture is retrieved along with the monofilament shuttle suture, which is then tied around the anchor suture limb (Fig. 20-14). The other end of the monofilament suture is pulled, bringing the anchor suture back through the tendon edge in retrograde fashion and out the portal (Fig. 20-15). In similar fashion, a twisted loop of Nitinol can be used to capture the anchor suture. Both techniques are simple and effective and can be performed using a number of different devices. The disadvantage in both is the additional step necessary first to pass the suture or wire, couple it to the anchor suture, and finally pull the anchor suture retrograde through the tendon to create the simple stitch. However, in situations in which there is little room available for larger instruments, as is often the case with small tears, this technique works well.

FIGURE 20-12 With the arthroscope in the lateral portal of this right shoulder, a cannulated suture passer enters from the posterior portal and moves to the articular side of the tear. With gentle rotation of the hand, the device penetrates the tendon from the articular to bursal surface.

FIGURE 20-13 After the passer penetrates the tendon, the monofilament suture is deployed into the subacromial space.

FIGURE 20-14 Viewed from the lateral portal, the monofilament and anchor suture are retrieved simultaneously and brought out the posterior portal, where they are joined with a half-hitch knot.

FIGURE 20-15 Viewed from the lateral portal, the monofilament suture is pulled from the posterior portal, drawing the anchor suture through the tendon and out the posterior portal, creating a simple stitch.

Knot Tying

A number of different arthroscopic knots have been described and each has its applicability and its proponents. The surgeon should become familiar and comfortable with one knot and proficient in its use. I use the SMC (Samsung Medical Center) knot, which has excellent sliding and locking characteristics, is a simple knot to tie and teach, and is very reproducible. The first step in knot tying is identification of the initial post, which should be the suture end that passes through the rotator cuff tendon. It is on this post that the sliding knot will be tied and introduced into the subacromial space. I shorten the first post and hold it in my left hand to accommodate for the length gained when the knot is pulled into the shoulder, and keep the two suture limbs even. The knot is made by bringing the long limb in the right hand around the index finger, under the left hand post limb, and back over both suture. This limb is then retrieved by reaching through the interval between the two sutures, brought back through them and, while pronating with the left hand, the right hand passes the nonpost limb through the D-shaped space created with the earlier maneuvers. The slack is taken out of the knot but is not tightened. The knot pusher is placed over the initial post, pushing the sliding knot down into the subacromial space to the tendon. Gentle traction is applied simultaneously on the initial left hand post while pushing the knot against the tendon, which will tighten the knot, and it is set and locked into place by pulling on the opposite right hand post. The final step consists of placing three half-hitches, reversing the throw and alternating the post each time. The knot pusher becomes a puller to deliver the half-hitches. The suture is then cut and its stability confirmed. This process is repeated for each subsequent suture.

Knotless Devices

With the growing interest in ARCR and, more recently, the interest in double-row repair, a number of manufacturers have devised knotless devices. The principle used in all these is that of interference fixation of the suture, either against the anchor itself or the surrounding bone. In theory, these anchors can capture the suture material after it has been passed through the tendon and secure it, maintaining loop tension in a manner comparable, if not superior to, that of traditional hand-tied knots. An example of the suture capture within the anchor is the Opus Magnum (ArthroCare, Sunnyvale, Calif).This anchor, after deployment, has a cinching mechanism that allows the surgeon to pull the tendon edge toward the anchor, achieving a repair. Variations on this concept have been used by a number of other manufacturers and have become more user-friendly and reproducible in their fixation. The PushLock (Arthrex, Naples, Fla) uses a bone-anchor interference to capture the sutures, with the suture material coursing on the outer surface of the anchor as it is impacted into the bone. The overriding principle in these and other knotless applications is avoidance of problems associated with knot tying.

When any of these devices are used in a double-row construct, the medial anchors are placed first, their sutures passed, and the medial suture limbs coupled to a lateral anchor. The medial sutures can be tied (Fig. 20-16), creating the medial row of fixation, and then brought out to the lateral anchor for fixation and creation of the second row of the DR (Figs. 20-17 and 20-18). Alternatively, these medial anchors sutures can be directly coupled to the lateral anchor without being tied medially.

FIGURE 20-16 Viewed from the posterior portal, this shows that all medial sutures are tied and their suture tails left long to be incorporated into the lateral anchors of the double row-repair.

FIGURE 20-17 In a right shoulder, viewed from the posterior portal, the medial suture limbs are brought laterally and coupled to knotless anchors.

FIGURE 20-18 Completed double-row repair viewed from the lateral portal.

Procedural Steps

Postoperative Days 1 to 7

Weeks 2 to 6

Weeks 7 to 12

Week 12

It is not uncommon for the patient to note an increase in the level of pain when strengthening exercises are added. They should be reassured and monitored accordingly.

The time for a return to athletic endeavors and/or light manual labor will differ from patient to patient, depending on the size of the tear, rehabilitation potential, and individual motivation. Most patients are told that discharge should be anticipated at 4 to 6 months but return to athletic endeavors and/or heavy manual work may take 6 to 9 months. Full maturation of the repair and ultimate return of strength can take longer than 12 months. Patients may note some achy discomfort, weather-related symptoms, and problems after repetitive overhead, use even after discharge. They should be instructed to use anti-inflammatories judiciously and, if they have persistent symptoms, to contact the surgeon for reevaluation.