ARTHROSCOPIC
ROTATOR CUFF REPAIR
T. Andrew Israel, MD
Luther Midelfort Orthopaedic &
Sports Medicine Center
OPERATIVE MANAGEMENT
OF ROTATOR CUFF TEARS
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Treatment Options
Treatment Principles
Surgical Indications
Advantages of ARCR
Disadvantages of ARCR
Technique for ARCR
Results
TREATMENT OPTIONS
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ASAD/debridement without repair
Open repair
Mini-open repair
Arthroscopic repair
TREATMENT PRINCIPLES
• Address associated pathology
• Adequate decompression
• Assess tear-size, retraction, pattern, tissue
quality, repairability
• Tendon mobilization
• Secure repair
• Supervised rehabilitation program
SURGICAL INDICATIONS
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Pain
Functional deficits
Failure to respond to nonoperative care
Full-thickness tear
Extensive partial-thickness tear
Acute injury
ADVANTAGES OF ARCR
• See both sides of cuff
• Visualize all pathology-labral tears, biceps,
OA, etc.
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Easier releases(esp. capsule)
Less pain, morbidity
Smaller scars
Better ROM
PATIENTS WANT IT!
DISADVANTAGES OF ARCR
• Learning curve
• ? Smaller contact area with bone for
healing
• High retear rate by ultrasound reported
• ? Pain from resorption of anchors
• Coding/reimbursement problems
TECHNIQUE FOR ARCR
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Define tear
Mobilize tendons
Prepare tuberosity
Cuff reduction
Place anchors
Suture management
Pass sutures through tear edge
Knot tying
DEFINE TEAR
• View from anterior and from posterior
• Measure with probe known size
• Trim ragged edges but preserve tissue
MOBILIZE TENDONS
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Place retention sutures
Release capsule
Anterior interval release
Posterior interval release
PREPARE TUBEROSITY
• Remove excrescences but preserve
cortex
• Trim tendon stump
• Define footprint
MARGIN CONVERGENCE
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Begin cuff reduction
Work medial to lateral
Side to side sutures
Tie knots
PLACE ANCHORS
• At lateral aspect of footprint
• Metal or biodegradable
• Make sure well fixed in bone
SUTURE MANAGEMENT
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Keep track of portals
Avoid tangles
Think one step ahead
Move at steady pace
PASS SUTURES THROUGH
TEAR EDGE
• Many devices available
• Avoid tearing tendon
• Line up puncture with anchor
KNOT TYING
• Perfect knots
• Perfect knots
• Flawlessly perfect knots
RESULTS
Gartsman, JBJS, 1998
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73 arthroscopic RCR
Average age 60.7 yrs
All pts followed at least 2 yrs(30 mons)
78% G/E relief of pain
90% G/E satisfaction
None of the shoulders were rated G/E
preop, 84% G/E @ most recent f/u
RESULTS
Burkhart, Arthroscopy, 2001
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59 arthroscopic RCR
Average follow-up 3.5 yrs
95% G/E result regardless of tear size
Rapid return overhead function(4 mons)
CASE PRESENTATION
CASE D.E.
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53 male RHD farmer
Left anterior shoulder pain x 2 years
No prior injury or surgery
Nonoperative Rx including PT, NSAIDS,
injections, activity modifications, etc.
PHYSICAL EXAM
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Crepitus with PROM
Tenderness greater tuberosity
AROM 155/170, 55/75, L5/T10
3/5 power abduction & external rotation
Positive impingement tests
SHOULDER ANATOMY
SURGERY
SUMMARY
• Much recent enthusiasm regarding
complete arthroscopic rotator cuff repair
• For many, this newer technique may be
preferable alternative to more traditional
mini-open rotator cuff repair
• Important that basic principles of rotator
cuff repair not be compromised
SUMMARY
• Several short-term studies demonstrate
excellent results comparable with those
of traditional techniques
• Choice of procedure based on variety of
considerations, including patient
expectations, pathoanatomy of the cuff,
and arthroscopic skills of the surgeon