Arthroscopic Treatment of Rotator Cuff Tears

 

 

 

 

 

DEFINITION

Rotator cuff disease encompasses a spectrum of disorders ranging from tendinitis to partial and fullthickness tendon tears.

It is the most common shoulder disorder treated by an orthopaedic surgeon, with over 17 million U.S. individuals at risk for the disabilities caused by the disease.

The prevalence of full-thickness tearing of the rotator cuff ranges from 7% to 40% across multiple studies.30,40

Age-related degenerative change is a primary factor in the development of rotator cuff tears.44 Asymptomatic full-thickness tears have been found in 10% of patients between 50 and 59 years old, 20% of patients between 60 and 69 years old, and 40.7% of patients 70 years old or older.21

The risks and benefits of both nonoperative and operative treatment must be considered for each individual patient.

A number of factors are critical in deciding how to treat full-thickness tears, including a history of trauma, patient age, tear size, tear retraction, degenerative muscle and tendon changes, and functional disability.

Traditionally, open rotator cuff repair was the standard of care for symptomatic full-thickness rotator cuff tears.

Several disadvantages are inherent to traditional open rotator cuff repairs. These include the need for deltoid detachment, difficult visualization of associated glenohumeral joint pathology, larger incisions, more extensive surgical dissection, and a higher complication rate.

The surgical treatment of full-thickness rotator cuff tears has evolved with the advent of arthroscopic techniques.

Rotator cuff repair techniques have progressed from mini-open repairs to repairs performed completely arthroscopically.

As techniques of arthroscopic rotator cuff repair have advanced, larger tears are also commonly repaired completely arthroscopically.

Single-row suture anchor repairs have been reported with good overall clinical results, but healing rates decrease as tear size increases.6,10

In some studies, biomechanical properties of the double-row repair are improved compared to singlerow repairs and include decreased strain over the footprint area, increased stiffness, and increased ultimate failure load.20,22,26,28 In other studies, modified single-row techniques have demonstrated

comparable biomechanical fixation strength to double-row techniques.17,25

In large and massive tears, double-row repair provides a higher rate of intact tendon healing than does traditional single-row repair; however, this benefit has not translated into clinically confirmed functional improvement or costeffective results.7,12

Recent study suggests that single-row repair may be preferable in certain situations, particularly when there is less than 10 mm of remnant tendon length.22

In the setting of a full-thickness rotator cuff tear, we perform a double-row suture anchor repair, a tension band repair, or a hybrid repair (double row and tension band) based on the clinical situation and surgeon preference.

 

 

ANATOMY

 

The rotator cuff is a complex of four muscles arising from the scapula and inserting onto the tuberosities of the proximal humerus.

 

The supraspinatus and infraspinatus muscles make up twothirds of the posterior rotator cuff. The two tendons fuse together and have a direct bony insertion.

 

When performing a double-row rotator cuff repair, knowledge of the dimensions of the rotator cuff insertion or “footprint” is critical.

 

 

The footprint of the supraspinatus is triangular in shape, with an average maximum medial to lateral length of 6.9 mm and an average maximum anteroposterior (AP) width31 of 12.6 mm.

 

The infraspinatus has a long tendinous portion in the superior half of the muscle, which curves anteriorly and extends to the anterolateral area of the highest impression of the greater tuberosity.31

 

The footprint of the infraspinatus is trapezoidal in shape, with an average maximum medial to lateral length of 10.2 mm and an average maximum AP width31 of 32.7 mm.

 

Suture anchor repair constructs using a single row of anchors have been shown to restore only 67% of the original footprint of the rotator cuff.2

 

Adding a second row of anchors increases the contact area of the repair by 60%.41

 

PATHOGENESIS

 

The etiology of rotator cuff tears is multifactorial.

 

The major factors are age-related degenerative changes of the tendon and physiologic loading.

 

 

 

The theory of age-related accumulative damage is supported by histologic findings of decreased fibrocartilage at the cuff insertion, decreased vascularity, fragmentation of the tendon with cellular loss, and disruption of Sharpey fiber attachments to bone.

 

 

Clinical studies support the aging theory as a primary cause of rotator cuff disorders.44

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In a review of 586 consecutive patients with unilateral shoulder pain, rotator cuff tears were found to be correlated with increasing age, with an almost perfect 10-year difference between patients with no tear, a unilateral tear, and bilateral tears.

 

The average age of patients presenting with rotator cuff-derived pain with no tear was 48.7 years old; unilateral tear, 58.7 years old; and bilateral tears, 67.8 years old.

 

 

Physiologic loading of the tendon has also been postulated as a mechanism for cuff tearing.

 

 

Localized degeneration of the articular region of the tendon, most commonly in the supraspinatus, is indicative of a tendon loading etiology.

 

Uniform changes throughout the entire tendon, which are not commonly found, would be more suggestive of an age-related degenerative process.

 

Age and loading likely have a multiplicative effect, with tendons in an older person both being more susceptible to damage from normal physiologic loading and exhibiting a worse healing response.

 

Genetics may also have a significant role in the predisposition for rotator cuff tears.

 

 

A strong relationship between rotator cuff tearing and family history has been shown.37

 

One study found a relative risk of 2.42 for full-thickness rotator cuff tears in siblings of patients with cuff tears versus controls.14

 

This increased risk in siblings implies that genetic factors may play a role in the development of rotator cuff tears.

 

NATURAL HISTORY

 

Information about the natural history of rotator cuff disease is fundamental to understanding treatment indications.

 

Because symptomatic tears are often treated, our understanding of the natural history of rotator cuff disease is based on the study of asymptomatic rotator cuff tears.

 

Asymptomatic tears are extremely common in the population, and many of these are at risk for the development of symptoms over time.

 

 

In one study, over 51% of patients with a previously asymptomatic rotator cuff tear and a contralateral symptomatic tear developed symptoms in the asymptomatic tear over an average of 2.8 years.45

 

Once a tear became symptomatic, 50% progressed in size. Only 20% of those remaining asymptomatic progressed in size.

 

No tears were found to decrease in size over time, suggesting that there was a limited intrinsic healing potential for the rotator cuff and that a significant percentage of patients with asymptomatic tears were at risk for symptom development.

 

Pain development in shoulders with an asymptomatic rotator cuff tear is associated with an increase in tear size.27,32,45

 

In addition, the potential for healing after surgery may be influenced by the irreversible muscle and tendon changes that occur in delayed repairs and in older patients.

 

Clinical evidence of spontaneous healing of partial-thickness tears also appears limited.

 

 

Partial-thickness tears are likely to progress to full-thickness tears over time and tear progression is associated with symptom development.27

 

In a cohort of subjects with an asymptomatic rotator cuff tear who were prospectively monitored, 40% of partialthickness tears progressed to full-thickness tears with pain development.27

PATIENT HISTORY AND PHYSICAL FINDINGS

 

 

Patients with rotator cuff disorders often complain of pain and/or weakness. The development of symptoms is often insidious.

 

There may be a recollection of minor trauma (eg, episode of heavy lifting, catching a heavy object).

 

Pain is usually localized to the anterior or anterolateral aspect of the shoulder, often extending down the front or side of the shoulder to the elbow.

 

Pain exacerbated with use, especially with overhead activities, is common.

 

 

Sleep disruption is also common in patients with symptomatic rotator cuff disease. Weakness is a complaint for patients with symptomatic fullthickness rotator cuff tears.

 

When asymptomatic, a rotator cuff tear is often associated with a clinically insignificant loss of shoulder function compared with an intact rotator cuff.18

 

Large tears in asymptomatic or symptomatic individuals are more likely to manifest in weakness21,29; however, pain from tendinitis or small tears may also simulate lack of strength.

 

 

Similarly, patients with large or massive tears may have very reasonable function. More commonly, however, these patients report overhead weakness and fatigue.

 

If gross weakness is recognized suddenly after a trauma, a rotator cuff injury should be suspected and investigated.

 

In the setting of chronic rotator cuff tears, inspection of the shoulder will often reveal atrophy of the supraspinatus and infraspinatus.

 

 

Prior surgical incisions should be noted. If previous open rotator cuff repair with deltoid detachment was performed, deltoid integrity should be assessed, along with axillary nerve function.

 

Range-of-motion testing should be performed both actively and passively.

 

Passive range of motion is often preserved except in the setting of chronic large tears where static superior head migration leads to limited forward elevation with inferior capsule contracture.

 

Posterior capsular contracture is also a common finding with both small and large tears.

 

Active motion is often limited in scapular plane elevation. This may be due to either weakness or pain.

 

 

Shoulder strength should be evaluated with manual muscle testing.21

 

 

Various arm positions will isolate the rotator cuff and specifically test these muscles for dysfunction.

 

The supraspinatus, infraspinatus, and teres minor can be isolated with resisted scapular plane elevation at 90 degrees in neutral rotation, resisted external rotation in full adduction and slight internal rotation, and external

 

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rotation in 90 degrees of abduction and 90 degrees of adduction, respectively.

 

The belly press, lift-off, or bear hug tests can be used to test subscapularis function.

 

Belly press test: Inability to maintain maximum internal rotation without the elbow dropping posterior to the midsagittal plane of the trunk indicates impaired subscapularis function.

 

Lift-off test: Inability to maintain active maximal internal rotation with hand off the lumbar spine without extending the elbow indicates impaired subscapularis function.

 

Bear hug test: Inability to maintain resisted internal rotation with the palm of the hand on the involved side placed on the opposite shoulder and the elbow positioned anterior to the body indicates impaired subscapularis function.

 

Electromyographic analysis has shown that the belly press activates the upper subscapularis, whereas the lift-off activates the lower subscapularis.

 

Special tests have been developed to aid in diagnosis:

 

 

The Neer impingement test (forward elevation in internal rotation) and the Hawkins impingement test (elevation to 90 degrees, cross-body adduction, and internal rotation) were designed to elicit symptoms by impinging the rotator cuff on the undersurface of the acromion and coracoacromial ligament.

 

The hornblower's sign indicates teres minor dysfunction or tearing if there is weakness or inability to achieve full external rotation in an abducted position.

 

A positive result (weakness or pain) with the empty can test (Jobe sign) indicates dysfunction of the supraspinatus tendon.

 

Inability to maintain the shoulder in a fully externally rotated position indicates a positive external rotation lag sign and significant dysfunction or tearing of the infraspinatus tendon.

 

Variable accuracy of these tests has been shown when used in isolation, but accuracy may be improved when used in combination with other provocative examinations.34

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Four standard shoulder radiographs should be taken for every patient evaluated for shoulder pain: AP, true AP with active shoulder abduction to 30 degrees in the scapular plane, axillary lateral, and scapular Y views.

 

 

The decision to obtain further imaging studies is based on radiographic findings along with data obtained from the history and physical examination.

 

In a patient with a small full-thickness rotator cuff tear, radiographs are usually normal.

 

With increasing tear chronicity, sclerotic and cystic changes of the greater tuberosity are often noted.

 

With increasing tear size, proximal humeral migration can be found on the AP and true AP views. Tears extending into the infraspinatus tendon are associated with greater humeral migration than is seen with isolated supraspinatus tears.19

 

Proximal migration is best identified on the true AP view as loss of a concentric reduction of the proximal humeral and glenoid centers of rotation.

 

Humeral elevation may be static or dynamic depending on the chronicity of the tear. Static elevation is associated with contracture of the inferior capsule.

 

Magnetic resonance imaging (MRI) of the shoulder in patients with rotator cuff tears evaluates both the tendon and muscle quality.

 

 

Full-thickness tears show increased signal intensity at the tendon insertion on T2-weighted images.

 

MRI has been shown to have over 90% sensitivity and specificity in detecting tears without previous surgery.

 

Fatty infiltration and atrophy of the rotator cuff musculature can also be identified on MRI.

 

Increased fatty infiltration of the rotator cuff muscles has been correlated with poorer tendon healing and worse final postoperative outcomes after repair.

 

In the hands of a skilled ultrasonographer, ultrasound has a sensitivity and specificity similar to that of MRI to identify rotator cuff tears as well as fatty infiltration of muscles.35,39,42

 

Benefits of ultrasound include limited radiation, ability to routinely perform bilateral examinations, and a dynamic component of the examination, which can significantly aid in differentiating scar from tendon.

 

The most significant limitation of ultrasound is the need for an experienced ultrasonographer.

 

Computed tomography (CT) and CT arthrography has been widely used in Europe for the diagnosis of rotator cuff tears.

 

 

In patients with pacemakers or aneurysm clips, CT arthrography is a good alternative to MRI. Limitations of CT include increased radiation exposure and poorer soft tissue resolution compared to MRI.

 

Similar to MRI, muscle quality, including atrophy and fatty infiltration, can be examined and has been shown to be predictive of tendon healing and outcomes after surgery.

 

DIFFERENTIAL DIAGNOSIS

 

Rotator cuff tendinitis

 

 

Partial-thickness rotator cuff tear Rotator cuff contusion

 

 

 

Adhesive capsulitis Arthritis or chondral injury Calcific tendinitis

 

 

 

Biceps tendon pathology (tendinitis or tearing) Suprascapular nerve entrapment or spinoglenoid notch cyst Internal impingement

NONOPERATIVE MANAGEMENT

 

The decision to pursue nonoperative management in the setting of a full-thickness rotator cuff tear depends on both patient and tear characteristics. Asymptomatic tears are extremely common, with MRI, ultrasound, and arthrography studies showing a 4% to 13% incidence in subjects 40 to 60 years old and over 50% in subjects

older than 80 years old.40 All asymptomatic tears should be treated nonoperatively. In subjects younger than 65 years old, serial monitoring with sequential MRI or ultrasounds is reasonable, given that over 51% of patients with a previously asymptomatic tear and a contralateral symptomatic tear will develop symptoms in

the asymptomatic shoulder over an average of 2.8 years.45

 

 

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For symptomatic tears, nonoperative treatment has shown moderate success, with 45% to 82% satisfactory

results; however, the results are with relatively short follow-up.4,16,24,43 As increasing patient age and tear enlargement are concerns with nonoperative management, it will be critical to understand whether nonoperative management is durable for extended and long follow-up. Nonoperative treatment includes anti-inflammatory medications and physical therapy. Modifiable factors such as scapulothoracic dyskinesia, decreased active abduction, and decreased strength in forward elevation and abduction are associated with

pain and loss of function and can be addressed nonoperatively with therapy.13 A limited number of subacromial cortisone injections may be performed, especially in patients who are not surgical candidates. Chronic large or massive rotator cuff tears in any age group or any chronic full-thickness tear in patients older than age 70 years should undergo an initial trial (at least 3 months) of nonoperative management. Because irreversible changes have already occurred to the cuff or the articular cartilage in most of these patients, it is safer to attempt nonoperative treatment for a period of time. Failure of nonsurgical treatment is an indication for arthroscopic repair.

 

SURGICAL MANAGEMENT

 

The decision to proceed with operative treatment of rotator cuff disease requires an evaluation of the risks and benefits associated with both surgical and nonsurgical treatment.

 

Although the risks of surgical management are well known, the risks of nonoperative treatment may not be so obvious.

 

 

Tear progression, muscle fatty infiltration/atrophy, and arthritis are potential irreversible risks of nonoperative treatment of rotator cuff tears.

 

Knowledge about these risks can help guide treatment.

 

Early surgical repair should be considered for all acute tears and any chronic small- or medium-sized symptomatic tears in patients younger than age 65 years.

 

 

These patients are at significant risk for developing the irreversible changes previously mentioned with prolonged nonoperative treatment.

 

Recent enlargement of a preexisting tear, especially if associated with a sudden decrease in function, should be considered for early repair.

 

These patients also have the greatest potential for healing. Consequently, the benefits of early surgical treatment combined with the inherent risks of prolonged nonoperative treatment are reasons for surgical repair.

 

Preoperative Planning

 

Tear size and chronicity will determine the difficulty of the repair, so careful preoperative imaging evaluation is important in surgical preparation.

 

 

If a tear is very large, the surgeon should make sure that a variety of different suture-passing devices are available to assist in the repair.

 

A Banana Suture Lasso (Arthrex, Naples, FL) can be passed through the Neviaser portal in large, medially retracted tears to shuttle suture through the tendon.

 

Angled Suture Lassos (Arthrex) can be placed through accessory portals to pass sutures from difficult angles not easily approached through the lateral working cannulas.

 

Larger anchors should be available if bone quality is poor.

 

The use of traction sutures within the free tendon edge helps to facilitate tendon mobilization techniques and suture passage.

 

Care is taken to assess for tendon delamination and potential differential retraction of tendon layers, especially posteriorly.

 

Chronic, larger tears may not be fully reducible over the anatomic cuff footprint. Techniques that lateralize the free edge of the tendon, such as margin convergence, may be necessary. Alternatively, repairing the tendon to the medial footprint only or partial tendon repairs may be warranted.

 

Assess preoperative motion after the patient is anesthetized but before initiating the surgical procedure. Patients with preoperative stiffness may be candidates for concomitant capsular release and/or manipulation prior to rotator cuff repair.8,15

Positioning

 

Beach-chair position advantages

 

 

The patient's shoulder is positioned in a nearly anatomic position, which facilitates orientation and visual understanding of shoulder anatomy while performing the repair.

 

Examination under anesthesia is facilitated by stabilizing the scapula in the beach-chair position compared with the lateral position.

 

The arm can be easily manipulated in surgery without the need to unhook it from a traction unit.

 

Traction is not required but can be added in an inferior direction to increase the subacromial working space.

 

Humeral rotational control is easily accomplished. This can be critical when working on different regions (anterior vs. posterior) of the greater tuberosity.

 

Conversion to an open procedure is easily performed without redraping.

 

Lateral decubitus position advantages

 

 

Many surgeons believe that the lateral position improves visualization and maneuverability of the scope due to traction.

 

It significantly improves inferior access to the glenohumeral joint, which makes it less difficult to perform glenohumeral procedures but has little impact on subacromial procedures.

 

Transient and permanent nerve damage has been reported due to traction in the lateral position. Consequently, we prefer to perform all subacromial procedures, including rotator cuff repair, in the beach-chair position.

 

 

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TECHNIQUES

• Double-Row Rotator Cuff Repair

Our indications for double-row repair are tears where potential limitations in biologic factors for healing exist: (1) larger tears (>3 cm), (2) poor quality tissue, (3) age older than 65 to 70 years, and (4) revision repairs.

Portal Placement and Cannula Insertion

The camera is placed in the subacromial space through a posterior portal.

 

 

Our preferred starting posterior portal is slightly more lateral than a standard posterior portal. This is done to gain better visualization of the lateral greater tuberosity during repair. Also, a slightly inferior position is preferred because portals will migrate superiorly with shoulder swelling.

 

A lateral working portal is developed under spinal needle localization. Portals should be placed low enough so that cannulas are introduced parallel to the rotator cuff tendon. This allows for easier subacromial instrumentation. The portal should be placed at about the midpoint of the tear in small- or medium-sized tears.

 

A second lateral portal can be placed in larger tears with cannulas separated by several centimeters. Clear, fully threaded 8.25-mm cannulas are placed in these portal sites.

 

Another large threaded cannula is placed through an anterolateral portal, anterior to the acromion, at the same level as the lateral and posterior portals. Again, maintaining low portal placement is critical so instruments will be passed parallel to the tendon, allowing the greatest excursion of instruments in the subacromial space. The anterolateral portal is mainly used as an accessory portal for suture retrieval and storage.

 

 

 

TECH FIG 1 • A. Rotator cuff tear viewed from lateral portal. B. Débrided greater tuberosity and two medial row anchors are inserted. C. Sutures passed through rotator cuff in horizontal mattress configuration. All sutures are exiting through the anterior cannula. D. Tied medial row sutures and planned suture configuration for lateral row anchor insertion. E. Lateral row anchor insertion with tensioning of rotator cuff. F. Final double-row repair construct viewed from a lateral portal.

Repair Site Preparation

 

A soft tissue ablation device is used through the lateral portal to clear all the soft tissue on the undersurface of the acromion extending posteriorly, including the soft tissue and fat around the scapular spine. A limited acromioplasty is performed when arthroscopic visualization demonstrates evidence of anterosuperior wear of the acromial arch. A superior capsular release and rotator interval-coracohumeral ligament release are performed when needed to allow a low-tension reduction of rotator cuff to its anatomic position. The need for this is more common with anterior supraspinatus tears, which are associated with a greater degree of retraction. Finally, a limited débridement of degenerative tendon edges is performed using an arthroscopic shaver.

 

Soft tissue is then removed from the rotator cuff insertion site on the greater tuberosity with a shaver, exposing cortical bone (TECH FIG 1). Care is taken not to perform a complete decortication that could compromise anchor fixation.

 

Mobility of the torn tendon is assessed with a tissue grasper through the lateral portal.

Anchor and Suture Placement

 

Once the tear has been determined to be repairable, a medial row of suture anchors (5.5-mm metal or BioComposite [Arthrex, Naples, FL] screw-in style) is placed. Anchors are loaded with two no. 2 FiberWire sutures (Arthrex).

 

For small- and medium-sized tears, one or two medial anchors are placed at the level of the articular margin (see TECH FIG 1). Each anchor is separated by 1 to 1.5 cm. Anchors are placed through small stab incisions just off the lateral border of the acromion.

 

For large and massive tears, we place three medial anchors.

 

 

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Sutures from the medial row of anchors are next passed through the tendon (see TECH FIG 1).

Starting with the most anterior anchor, both strands from one suture are passed through the tendon at the anterior aspect of the tear in a horizontal mattress fashion. Sutures are passed approximately 1 to

1.5 cm medially to the lateral edge of the tear. Sutures are retrieved and stored in the anterolateral cannula. Both strands of the second suture are then passed posteriorly to the first suture, again in a horizontal mattress configuration.

 

The steps are repeated for the posterior anchor of the medial row.

 

Once all strands are passed through the tendon, sutures are sequentially retrieved through the lateral cannula and tied using an arthroscopic knot pusher. Appropriate tendon reduction is facilitated by securing the anterior most sutures first. Once tied, suture strands can be retrieved through an accessory cannula or through the incision used for anchor insertion (see TECH FIG 1).

 

Bursal tissue is then removed lateral to the rotator cuff footprint in order to visualize the insertion site for the lateral row anchor(s). The anchors are placed lateral to the lateral edge of the footprint to maximize the tendon contact with the footprint. If two medial row anchors are placed, we generally place two lateral row anchors. One strand from each knot is retrieved through the lateral cannula and passed through a 5.5-mm self-punching, BioComposite anchor. Sutures are minimally tensioned prior to final anchor insertion with care taken to avoid sinking the anchor below the cortical surface (see TECH FIG 1). This step is repeated with the remaining suture limb from each knot using a second 5.5-mm self-punching, BioComposite anchor (see TECH FIG 3).

• Knotless, Single-Row (Tension Band) Rotator Cuff Repair

   

  This repair technique follows the previous repair technique in terms of rotator cuff and repair site preparation.

   

  Using the lateral cannula and a suture-passing device, a no. 2 FiberWire suture is passed into the anterior rotator cuff tendon in a horizontal mattress configuration. Both limbs of the suture are retrieved from the anterolateral cannula. Sutures are passed approximately 1 cm medial to the lateral edge of the tear (TECH FIG 2).

   

  One limb of a second no. 2 FiberWire suture is then passed anterior and adjacent to the posterior strand of the first suture. The second limb is passed approximately 1 cm posteriorly.

   

   

   

  TECH FIG 2 • A. Rotator cuff footprint and remnant tendon stump viewed from posterolateral portal. B. Arthroscopic burr used to débride greater tuberosity. C. Débrided tuberosity and rotator cuff tear are visualized. D. Two no. 2 FiberWire suture passed with the anterior limb of posterior suture placed adjacent and anterior to the posterior limb of the anterior suture. E. Sutures exiting through an anterolateral cannula. F. Final construct after two lateral row anchors are inserted, and the cuff is appropriately tensioned.

   

   

  The row of anchors is placed lateral to the lateral edge of the rotator cuff footprint. If two FiberWire sutures are used, we generally place two lateral row anchors. Both strands from the posterior suture are retrieved through the lateral cannula and passed through a 5.5-mm self-punching, BioComposite anchor (see TECH FIG 2). Sutures are tensioned to reduce the rotator cuff to the footprint prior to final anchor insertion. Again, care is taken to avoid sinking the anchor below the cortical surface. This step is repeated with the anterior suture, using a second 5.5-mm self-punching, BioComposite anchor (TECH FIG 3).

   

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  TECH FIG 3 • A. Diagram showing the final double-row repair using two medial screw-in anchors and two lateral SwiveLock (Arthrex) anchors. B. Diagram showing the final single-row, tension band repair with two lateral SwiveLock anchors.

   

   

   

  PEARLS AND PITFALLS

   

  Portal placement

  • The posterior portal should be placed more lateral than the standard portal site (standard portal site: 2 cm medial and 2 cm inferior to the posterolateral corner of the acromion) for improved access to the lateral aspect of the greater tuberosity.

  • Portal placement should err low to facilitate instrumentation after shoulder swelling.

     

    Surgical anatomy

    • Landmarks should be precisely drawn on the shoulder before arthroscopy to ensure accurate portal placement.

       

      Hemostasis ▪ Preoperative (5-10 minutes) subacromial injection of local anesthetic with epinephrine in the subacromial space will significantly reduce bleeding during repair.

      • During soft tissue removal around the scapular spine and coracoacromial ligament release along the anteroinferior acromion, the surgeon must watch for vessels that require coagulation.

 

Accurate assessment of tear anatomy

• Tear pattern/anatomy can be highly variable and is critical for appropriate reconstruction of the repair footprint. Additionally, understanding tear anatomy can underscore a need for side-to-side or margin convergence repairs. The tear pattern can often be difficult to determine if viewing from a single portal. In order to fully understand the tear pattern and to ensure tear mobilization, we routinely view the rotator cuff from both the posterior and lateral portals.

 

Avoid overreduction of the rotator cuff

Care should be taken to avoid far medial suture passage to avoid overreduction and tension on the rotator cuff. We recommend passing sutures approximately 1 cm medially. Similarly, when tensioning lateral, knotless anchors, we recommend watching the rotator cuff tendon reduction to the footprint to avoid overtensioning.

 

 

 

POSTOPERATIVE CARE

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All patients are initially placed in a sling, which is removed only for elbow range-of-motion exercises three or four times per day to limit elbow stiffness and for bathing.

 

 

 

Dressings are removed on the second postoperative day and showering is allowed the following day. Patients are seen at 10 days postoperatively for suture removal.

 

When to start physical therapy after rotator cuff repair is debated among orthopaedic surgeons. The decision

is based on the perceived risks and benefits of early motion.

 

 

The major benefit of early motion is the potential limitation of postoperative shoulder stiffness. The main risks include repair disruption and limited healing.

 

Early passive motion has historically been recommended after open rotator cuff repair. With the advent of arthroscopic repairs, scarring from soft tissue dissection is minimized, so limiting early motion is possible.

 

 

Limited early motion likely does not compromise healing in small- to medium-sized tears.3,23

 

Several factors, including tear size, tendon and bone quality, and preoperative motion, should be considered in this decision.

 

With osteoporotic bone or extremely poor tendon quality, limiting motion initially after repair is recommended.

 

Preoperative shoulder motion is an important factor in determining the initiation of motion. Earlier motion may be initiated if preoperative motion is limited and requires manipulation or release at the time of repair.

 

In general, tear size is the most important factor in determining the timing of postoperative rehabilitation.

 

 

Limiting early motion in patients with larger tears may provide improved healing potential, given that their overall healing rates are much lower than smaller tears.6,10,11

 

Patients with small- or medium-sized tears remain in a sling for the first 6 weeks after surgery.

 

 

 

Elbow and hand range-of-motion exercises are started immediately. No shoulder motion is allowed during the first 6 postoperative weeks.

 

If there was a significant preoperative motion deficit requiring surgical release or manipulation at the time of repair, early passive motion is allowed.

 

After 6 weeks, the sling is removed and patients are started on passive- and active-assisted range-of-motion exercises including forward elevation in the scapular plane, external rotation in full adduction, and pendulum and pulley exercises.

 

Internal rotation and shoulder extension is limited, and patients are instructed not to perform any lifting, pushing, pulling, or overhead activity.

 

At 3 months after surgery, strengthening exercises are initiated. These begin with isometric exercises and progress to isotonic exercises, with a stretching program maintained throughout.

 

Return to sports and full unrestricted activity is allowed at 4 to 5 months.

 

For large or massive tears, patients remain in a sling with no shoulder motion for 6 weeks.

 

 

At 6 weeks, the sling is removed and patients are allowed to lift the arm to shoulder height only.

 

Formal physical therapy is not initiated at this time. Instead, a shoulder continuous passive motion (CPM) device (Breg Flexmate S500, Breg, Inc., Vista, CA) is used to regain forward elevation in the scapular plane. CPM use is continued until 3 months postoperatively.

 

At this time, formal physical therapy is initiated, including passive and active motion and strengthening as per the protocol for small- and medium-sized tears.

 

Return to sports and unrestricted activities is allowed at 6 months postoperatively.

 

 

 

OUTCOMES

Functional outcomes after both open and arthroscopic rotator cuff repair have been reported to be

durable at long-term follow-up.5,9,11 A number of factors have been correlated with outcomes after repair, including patient age, tear size, tear acuity, workers' compensation status, preoperative smoking status, muscle quality, and tendon healing.

In both open and arthroscopic repairs, tendon healing is correlated with improved outcomes.5,8,9 Healing maybe more important in younger or active patients in terms of achieving a painless functional shoulder.

There are limited series reporting the outcomes of complete arthroscopic double-row rotator cuff repairs.

 

Sugaya et al36 compared healing rates and outcomes between single- and double-row repairs in 78 patients at an average of 35 months after surgery using MRI. There were significant improvements in University of California Los Angeles (UCLA) and American Shoulder and Elbow Surgeons (ASES) scores in both repair groups, with no significant difference found between techniques. There was a significant increase in retear rates with single-row repairs.

Anderson et al1 recently evaluated 48 patients at a mean of 30 months after double-row repair with ultrasonography. There was a significant improvement in active motion, strength, and outcomes when compared to preoperative values. The overall retear rate was 17%, with no significant difference in outcomes between healed and retorn tendons. Healed shoulders were significantly stronger in elevation and external rotation.

In their series of double-row repairs, Tashjian et al38 noted that increased age and longer duration of follow-up were associated with lower healing rates after double-row rotator cuff repair. They concluded that the biologic limitation at the repair site, as reflected by the effects of age on healing, appeared to be the most important factor influencing tendon healing.

No study has clinically compared a single-row, tension band repair to double-row repair

 

 

COMPLICATIONS

Several factors can be directly correlated with persistent pain and limited function after repair.

These factors are broken down into three categories: surgeon-controlled, non-surgeon-controlled, and patientrelated factors.

They include incorrect or incomplete diagnosis, surgical technical error, stiffness, infection, and anesthesia-related complications.

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Continued pain after rotator cuff repair can often occur if a second pathology is not identified and treated.

Conditions often confused with rotator cuff disease include cervical spine disorders, suprascapular neuropathy, acromioclavicular joint arthritis, biceps tendinopathy, glenohumeral instability or arthritis, labral tears, and frozen shoulder.

A complete history and physical examination can prevent missing several of these problems, which can often be treated concomitantly at the time of rotator cuff repair.

Technical problems leading to persistent pain and dysfunction after repair can be grouped into repair failures, deltoid detachment, neurologic injury, excess fluid extravasation, and patient positioning injuries.

The most likely reason for failure of tendon healing after repair is patient age.

 

Poor surgical techniques, including poor knot-tying, limited fixation (number of anchors), and poor anchor insertion technique, can all lead to a weak biomechanical construct.

 

Deltoid detachment is avoided in the setting of complete arthroscopic repair; but if a mini-open approach is performed, then excess detachment without bony repair can lead to failure of healing.

 

Transient neurologic injury can occur secondary to excess traction when the lateral position is used.

 

Proper portal placement is critical to avoid axillary (posterior and lateral portals) and musculocutaneous (anterior portal) nerve injury.

 

Excess swelling due to fluid extravasation into the deltoid can significantly raise intramuscular pressures. Therefore, pump pressures should be kept below 50 mm Hg, with procedure times less than 2 hours.

 

Proper padding around the knees (lateral position) and flexing the hips and knees (beach-chair position) can avoid iatrogenic problems secondary to positioning.

 

Postoperative stiffness is another potential complication.

 

With limited surgical dissection associated with complete arthroscopic repairs, the risk of stiffness may be significantly reduced when compared with open repairs.

 

Most shoulders with early motion loss recover motion and rarely require capsular release.33

 

If significant stiffness does develop that is resistant to therapy, arthroscopic lysis of adhesions in the subacromial space along with capsular release is recommended.

 

Infection after rotator cuff repair is uncommon.

 

Most series report infection rates of 1% to 2% after open or mini-open rotator cuff repairs.

 

Although there are few reported studies of infection rates after complete arthroscopic repairs, it appears that infection is less common than after open or mini-open repairs.

 

Diagnosis is often delayed in cases of postoperative infection, and persistent wound drainage is the most consistent examination finding.

 

Cultures will often grow Propionibacterium acnes, Staphylococcus aureus, and coagulase-negative S. aureus.

 

P. acnes often takes 7 to 10 days to grow on cultures. Therefore, cultures should be held in the setting of postoperative infections for at least 1 week.

 

Treatment consists of multiple débridements and intravenous antibiotics for usually 6 weeks.

 

Outcomes after infection are satisfactory, although significant delays in diagnosis or treatment can lead to inferior results.

 

Anesthetic complications can occur after rotator cuff repair.

 

If general anesthesia is used, major complications occur less than 1% of the time.

 

More commonly, nausea, inability to void, and severe pain are the complications seen in the setting of outpatient elective shoulder surgery.

 

Temporary Horner syndrome, phrenic nerve paralysis, and recurrent laryngeal nerve block are common but usually without significant consequence.

 

Intraneural injection or needle injury to the nerve roots can occur.

 

Symptoms such as persistent paresthesias or numbness can be irritating but usually resolve with time (possibly several months).

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