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Technique: Arthroscopic rotator cuff repair using modified Arthrex suture-bridge technique

    Overview

    Learn the Arthroscopic rotator cuff repair using modified Arthrex suture-bridge technique surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Arthroscopic rotator cuff repair using modified Arthrex suture-bridge technique surgical procedure.
    Rotator cuff tears are a relatively common cause of shoulder pain from the subacromial space. The rotator cuff disease that may result in tears can be thought of in the main as resulting from either intrinsic or extrinsic factors or a combination of the two.
    Intrinsic disease occurs due to a patient’s biological and genetic makeup, resulting in disorganisation of the collagen within the tendon, which degenerates and detaches from its bony footprint on the proximal humerus. Extrinsic causes are thought to be attritional wear from repetitive rotation and movement against a thickened coracoacromial ligament and subacromial bony spur, resulting in rupture of the rotator cuff tendon attachment to the proximal humerus. Rotator cuff tears can also come about as a result of direct injury, with a fall or wrenching force to the joint or even a direct blow to the effected shoulder.
    Rotator cuff tears can be further categorised as partial thickness or full thickness tears. The latter is a complete deficit of the tendon with detachment from the bone whereas the former describes fraying and scuffing of the upper (bursal) aspect or under (articular surface) aspect of the tendon. There may also be an element of intrinsic intra-substance change within the tendon structure which may only be apparent on cross-sectional imaging such as MRI scan.
    Much has been published in the orthopaedic literature concerning the management of rotator cuff disease and tears and despite this its management is controversial with fervent supporters of both conservative and surgical treatment. Many shoulder surgeons will advocate surgical repair of a torn or detached tendon once conservative measures have been proven to be unsuccessful. The exact surgical technique varies with surgeons’ preference and ability and there is little evidence to suggest that different surgical techniques have widely different surgical outcomes.
    The technique I describe here is one I use for a small to medium sized full thickness rotator cuff tear. I also use the same technique when taking down a partial thickness tear and fully detaching it to allow a radical debridement of degenerate tendon from its insertion. The tendon repair is then supplemented with subacromial decompression as demonstrated in this operative technique.
    Readers will also find of interest Mark Crowthers’ related technique Arthroscopic subacromial decompression

    Indications

    Indications
    Indication for this surgical procedure is an acute or chronic or even acute on chronic full thickness tear of the rotator cuff insertion. Ideally this is a small to medium sized tear of supraspinatus or infraspinatus. The same technique could be used for subscapularis tendon however this is much less common. Usually acute tears are traumatic in nature whereas chronic tears are more likely to be degenerate.
    Symptoms and Examination
    Usually patients present with pain, dysfunction and weakness in their affected shoulder. There maybe a history of an injury such as a fall or wrenching to the shoulder resulting in pain and subsequent weakness. Patients usually describe pain at the front or down the side of the shoulder radiating to the mid upper arm region. They may feel pain lying on that side and exacerbations of the pain are typically felt during activities particularly lifting and using the arm above shoulder height, particularly with repetition. The shoulder should be closely inspected and compared to the opposite side looking for any signs of asymmetry indicating muscle wasting, particularly around the back of the scapular in the supra- and infraspinatus fossae. Examination should ascertain whether the patient has maintained a full range of motion and then strength with formal testing of rotator cuff strength. Resistance to shoulder elevation in the plane of the scapular will reproduce pain and probable weakness in comparison to the opposite side. As always in examining the shoulder careful assessment of any neurological deficit should be ascertained. The patient will often have positive subacromial impingement signs with pain reproduced with any rotation of the proximal humerus underneath the coracoacromial arch. Particularly such manoeuvres with resistance will reproduce and give a fairly sharp pain in the usual site of pain.
    Imaging
    In patients with a painful and weak shoulder it is mandatory to obtain plain x-ray films. I always request 3 views with an anteroposterior (AP) view of the glenohumeral joint, a lateral outlet view to show the morphology of the acromion and an axillary view with shoot through of the axilla. X-rays will give an idea as to whether there is a subacromial spur, on the axillary view ascertain whether there is an os acromiale and give an indication from all 3 views as to whether there is any arthritis of the glenohumeral or acromioclavicular joints. If there is clinical suspicion of a rotator cuff tear then further imaging is usually indicated. This can be performed either in the form of an ultrasound scan performed by the surgeon themselves or by a sonographer or radiologist. Ultrasound scanning is user dependent and relies on dynamic interpretation of the images. The alternative would be to consider an MRI scan which will give excellent images of the shoulder anatomy and confirm whether or not there is a rotator cuff tear.
    Alternative Operative Treatment
    There are many described techniques for repairing rotator cuff tears, either as an open operation or mini open surgery as well as numerous arthroscopic techniques which have developed over the last 20-30 years. Most of the techniques involve direct repair of the tendon to the bone, either using interosseous or transosseous suture techniques or more recently using bone anchors which are widely available on the market. Rotator cuff repair surgery is usually performed in combination with subacromial decompression namely release and excision of the coracoacromial ligament, subacromial bursectomy and bony acromioplasty. This decompression opens the subacromial space and allows for swelling around the repaired tendon, and removing the potentially causative irritant of a thickened coracoacromial ligament and bone spur from the acromion.
    Non-operative Management
    There is never an absolute indication for surgical intervention in a patient with subacromial pain and a rotator cuff tear. Non-operative management involves rest with suitable tablet analgesia or anti-inflammatory medication. Subacromial injection of steroid and local anaesthetic should be considered in combination with a course of physiotherapy to guide rehabilitation exercises to regain range of motion and then strengthening of shoulder function. In the presence of a small rotator cuff tear such management can be successful. Subacromial injections may be transiently beneficial only for symptoms to return at a later date due to the underlying mechanical disruption. In some patients with suitable rest, time and rehabilitation their symptoms improve or disappear, such that they can regain function acceptable to their demands and requirements for daily activities. Surgery should only be considered in cases were non-operative treatment has failed to result in the desired outcome for an individual.
    Contraindications
    The patient’s general medical health and comorbidities must be taken into consideration. Medical comorbidities are a relative contraindication and a multi-disciplinary approach to pre-operative workup and management with medical and anaesthetic colleagues is essential. The patient must be able to co-operate with the immediate and prolonged perioperative management and rehabilitation to optimise their outcome.

    Setup

    The procedure is performed in the beach-chair position using an appropriate operating table attachment and under general anaesthetic (aiming to keep systolic blood pressure at approximately 100 mmHg) supplemented by suprascapular nerve block (performed by the anaesthetist under ultrasound guidance). An alternative, depending on the patient’s medical and pain relief requirements, is to use an interscalene brachial plexus nerve block. Flowtron intermittent calf compression is used as mechanical thromboembolic prophylaxis. No prophylactic antibiotics are required for such shoulder arthroscopy. I use the T-Max (marketed in UK by Smith & Nephew) table attachment as shown. The patient is slid onto the table and both side supports are fixed in position. The wedge is then placed under the patient’s legs and the power assisted table attachment can then be elevated to a suitable beach chair position. The patient’s head is positioned safely on the table head piece adjusting the position with the anaesthetist’s approval and secured using the foam face mask clipped into position as shown. The Trimano (Arthrex) arm positioner is attached to the edge of the operating table in a position that will reach the operated arm. The Trimano is then covered with the sterile plastic cover attaching the black fitment to it’s end. Starting with the hand the whole upper limb to the shoulder to the base of the neck and across the axilla and chest wall is prepared with Chlorhexidine and then covered with a specifically designed beach chair shoulder arthroscopy drape. The blue foam arm holder is clicked into place on the black Trimano fitment and then folded over and secured with the Velcro edges to wrap the forearm. The blue foam arm holder is then wrapped in self adhesive stretch tape to hold the arm in position during surgery. The Trimano can be single handedly manoeuvered to hold the shoulder in different positions during the operation with traction as required. A 30o shoulder arthroscope is used and the arthroscopic pump instils saline at approximately 50mmHg

    Operation – 1

    AP (anteroposterior) plain x-ray right shoulder.
    This shows well aligned glenohumeral joint with no evidence of arthritis in the ball and socket. There is minor sclerosis at the greater tuberosity and significant sclerosis at the lateral edge of the acromion indicating a subacromial spur. There is some age related degenerate change within the acromioclavicular joint which is likely to be asymptomatic and an incidental finding.

    Plain lateral x-ray right shoulder. This shows a slight curve to the acromion process of the scapular but little else of significance.

    Ultrasound image indicating thinning and likely rotator cuff tear. Two markers within the rotator cuff tendon (R) are marked over the top of the humerus bone (H). The sonographer feels that the findings are of a thinned and likely torn supraspinatus tendon.

    This second ultrasound image also indicates a thinning and likely full thickness tear of the rotator cuff insertion.

    Position patient in beach-chair and prepare skin with chlorhexidine.Once the patient is positioned into the beach-chair position in the operating theatre preparation of the upper limb is started. Here clear chlorhexidine solution is used to prepare the hand.

    The prepared hand is now covered in a cloth stockinette and orange staining chlorhexidine solution is used to prepare the shoulder and the rest of the upper limb.

    Once the whole limb and shoulder girdle is covered in skin preparation the stockinette can be rolled down over the patient’s elbow.

    Apply beach-chair sterile drape with water capture pouch.A beach chair specific shoulder arthroscopy drape is passed over the patient’s arm and secured in position with the plastic water capture bag beneath the arm to collect arthroscopic fluid.

    Assemble Spider 2 arm positioner and secure forearm.The Spider 2 arm holder is put into position. Here the blue material arm glove is attached to the spider.

    Forearm is placed into the blue glove and on to the spider.

    The blue material arm glove attachment is wrapped around the patient’s arm and secured with the Velcro straps

    Final position of the forearm in the arm holder secured with the Velcro straps.

    Final position of the arm ready to start the operation.

    Instil local anaesthetic with adrenaline to glenohumeral joint, subacromial space and predicted portal sites – posterior, lateral and superolateral, once set up.The shoulder is injected with 20ml 0.5% bupivacaine with adrenaline. Here the glenohumeral joint is instilled from posteriorly. Some local anaesthetic is then injected into the subacromial space and around the region of the predicted arthroscopic port sites.

    I use the Arthrex shoulder repair instruments and here the instrument tray is checked showing relevant pieces: switching stick (SS) and the gold handled cannula introducer (CI) for the 8.25mm yellow cannula to be used

    More instruments from the Arthrex shoulder repair kit: blue handled knot pusher (KP); cuff grasper (CG); suture retriever (SR) and suture cutter (SC)

    Create the posterior portal first, 2 cms medial and 2 cms below the posterolateral corner of the acromion.No 11 scalpel blade is used to make a stab incision in the posterior shoulder soft spot.

    The trocar is placed into the posterior portal and into the glenohumeral joint. Keeping this perpendicular with the spine of the scapula and directed towards the coracoid process palpated anteriorly, the trocar is advanced into the glenohumeral joint with a pop as it penetrates the posterior glenohumeral joint capsule.

    This shows the position of the arthroscope sheath within the glenohumeral joint from the posterior portal.

    Arthroscope is then placed into the sheath in the glenohumeral joint.

    Insert arthroscope into glenohumeral joint from the posterior portal.This shows the glenoid (G) and the long head of biceps (LHB) tendon. The pink tissue between the middle glenohumeral ligament (MGHL) and long head of biceps is slightly inflamed synovium lining the rotator interval capsule.

    Rotating the arthroscope light lead changes the direction of the 30 degree angled arthroscope lens and allows inspection of all areas of the glenohumeral joint. Here a white needle has been placed into the anterosuperior aspect of the shoulder to release an air bubble within the joint.

    Inspect glenohumeral joint structures.Further image within the glenohumeral joint. This shows a sub-labral foramen (SLF). Also visible is the tendon of subscapularis (SSc) and the middle glenohumeral ligament (MGHL). To the right of the image is the humeral head (HH).

    Rotation of the light lead allows the rest of the glenohumeral joint, particularly the glenoid (G), to be inspected.

    Rotating the light lead in the opposite direction allows inspection of the humeral head (HH) and this confirms that there is no evidence of arthritis on the joint surface.

    Operation – 2

    Identify articular surface of supraspinatus rotator cuff tear.At the top of the Humeral Head (HH) the rotator cuff tear (RCT) is found at the front of the supraspinatus tendon (SSp). This is the most common site of a rotator cuff tear which can extend posteriorly across the whole of supraspinatus and into infraspinatus. The tendons of supraspinatus and infraspinatus can be thought of as one continuum as they merge once they come round the spine of scapula.

    Identify position for lateral portal using hypodermic needle through subacromial space into rotator cuff tear.Viewing from outside the white needle is taken from the top of the shoulder and then placed laterally with a view to passing this through the subacromial space and through the rotator cuff tear into the glenohumeral joint. This is done by palpating the lateral border of the acromion and the space below it and having seen from the arthroscope knowing the site of the tear and it’s relationship to the front of the acromion which can also be palpated.

    Looking from behind, the position of the arthroscope can be seen in the posterior portal and the position of the white needle placed from lateral.

    Once this has been viewed directly with the arthroscope seeing the bevel of the needle come through the rotator cuff tear, the needle can be removed and using the No. 11 scalpel blade the lateral portal can be created under direct vision. This goes straight through deltoid muscle but should be away from the axillary nerve which runs on deltoid’s under surface 5-7cm distal to the acromion.

    Introduce the ablation wand into the glenohumeral joint via lateral portal and through rotator cuff tear.The Werewolf (Smith & Nephew) radio frequency ablation wand (W) is here placed into the lateral portal. The controls can be seen on the black handle with a yellow button for ablation and a blue button for coagulation.

    Prepare torn edge of rotator cuff tendon and bony footprint of great tuberosity using radiofrequency ablation wand and high speed shaver.Intra-articular arthroscopic image showing the electrode end of the ablation wand within the cavity of the rotator cuff tear, starting to clear soft tissue from the bony footprint of the proximal humerus greater tuberosity. Take care to avoid damaging the long head of biceps tendon and normal supraspinatus inserted on the footprint. Exposing the bone is important so it can be further prepared to a bleeding surface onto which the torn tendon will be repaired with a view to healing and optimising function.

    This external image shows that the ablation wand has been removed and replaced by the arthroscopic shaver (S) into the lateral portal. I use the Smith & Nephew ‘bone cutter’ attachment. This is effective in clearing both soft tissue and bone using either oscillate or fast forward modes.

    Intra-articular arthroscopic image showing the cylindrical blade of the arthroscopic shaver within the rotator cuff tear debriding the soft tissue from the undersurface of the rotator cuff tear and clearing residual soft tissue from the bony footprint that wasn’t cleared by the ablation wand. The aim of this is to stimulate healing of the tissues, tendon to bone, once the repair is complete.

    Here the shaver is being used to clear the bone from the greater tuberosity footprint (FP) in the high speed fast forward mode which efficiently removes hard cortical bone revealing bleeding cancellous bone on the greater tuberosity. Whilst I use a single shaver attachment for all parts of this operation many alternative shaver blades or burrs are available and could be used as an alternative.

    External image of the position of the operating equipment whilst operating with the arthroscope in the posterior portal and the shaver in the lateral portal of the shoulder. To the left-hand side, can be seen the position of the arthroscopic monitor (M) on the stack with the image capture system (IC). Also present is the arthroscopic pump (AP) which is pumping the fluid into the arthroscopic sheath.

    Arthroscopic image as seen from previous step on the monitor showing the arthroscopic shaver preparing the undersurface of the rotator cuff tendon.

    This image from the glenohumeral joint shows completed preparation of the edge of the rotator cuff tear (RCT). Only minimal resection of the tendon edge has been required and no releases are necessary as it has not retracted and is relatively undisplaced.

    Move arthroscope from glenohumeral joint into subacromial space.External image showing arthroscope removed from the posterior portal and trocar placed within the sheath.

    Sheath and trocar are placed back into the posterior portal and is now advanced into the subacromial space. This is done by dropping the hand towards the floor and aiming for the anterolateral tip of the acromion which is here palpated by the surgeon’s left index finger. This should be an easy passage into the capacious space beneath the acromion superiorly, deltoid muscle around posteriorly, laterally and anteriorly with humeral head below and spine of scapula and rotator cuff muscle bellies medially.

    Trocar is removed from the sheath and water exits the sheath indicating that the sheath is within the subacromial space. Arthroscopic irrigation fluid has passed through the rotator cuff tear from the glenohumeral joint into the subacromial space.

    Arthroscope replaced into the sheath and into the subacromial space.

    Inspect subacromial space to identify coracoacromial ligament and rotator cuff tear.Arthroscopic image from the subacromial space showing the scuffed coracoacromial ligament (CAL) at the top of the image on the undersurface of the acromion. At the lower part of the image the bursal surface of the rotator cuff (RCb) is seen with some fibrillation on the superficial surface. This indicates attritional rubbing between the two surfaces know as the ‘kissing lesion’ which is arthroscopic evidence of subacromial impingement resulting in pain.

    Further image viewing around the subacromial space showing fibrillation of both the coracoacromial ligament above and the bursal surface of the rotator cuff below. All aspects of the space can be inspected by moving the arthroscope and hence pointing the lens at the end of the scope in the desired direction and then rotating the light lead which rotates the 30 degree angle of the lens to look up & down and side to side.

    Insertion of the radio frequency ablation wand into the lateral portal and into the subacromial space allows clearance of soft tissue bursal material.

    External image showing position of ablation wand from the lateral portal into the subacromial space.

    Clear subacromial bursal tissue and start reflecting coraco-acromial ligament from the acromion using the wand.Arthroscopic image showing the wand from the lateral portal ablating and clearing the coracoacromial ligament tissue from the undersurface of the acromion. It is important at this stage to identify bone of the undersurface of the acromion deep to the ligament. The aim of this step is to release the ligament from the undersurface of the acromion with a view to excising it by amputating it more distally before it inserts on the coracoid process.

    Further clearance of the coracoacromial ligament (CAL) tissue from the bony acromion (Acr).

    External view showing ablation wand clearing soft tissue from the acromion on the arthroscopic monitor.

    Arthroscopic image showing ablation wand clearing ligament tissue from the undersurface of the acromion, peeling it as a sheet away from the undersurface of the acromion and dissecting medially towards the coracoid. There are blood vessels in and around the ligament which can bleed briskly when divided so be ready to change from the yellow ablation pedal or button to the blue coagulation pedal or button to ensure prompt haemostasis and maintenance of a clear arthroscopic view.

    Detach coracoacromial ligament from acromion and coracoid and remove from subacromial space with a broad grasper. This reveals the subacromial spur.Arthroscopic image of the subacromial space showing the mobilised coracoacromial ligament (CAL) from the acromion above (Acr).

    Operation – 3

    Arthroscopic image showing grasper (G) placed into the lateral portal taking hold of the mobilised coracoacromial ligament fragment. This is then removed from the subacromial space.

    Removal of the section of coracocaromial ligament reveals the undersurface of the acromion. Here there is a moderate subacromial spur (SAS) cleared of soft tissue. The presence of a spur is thought to be as a result of bone being laid down due to pressure and traction on the coracoacromial ligament over years of repetitive bouncing of the proximal humerus with attached rotator cuff insertion against the ligament. A really large spur is ossification of the ligament tissue attached to the undersurface of the acromion.

    Inspect the rotator cuff tear.Rotating the light source and looking down towards the rotator cuff, shows the edge of the torn tendon to the left of the image and the bony footprint (FP) on the right.

    External image showing position of arthroscope in the lateral portal. A white hypodermic needle is inserted superiorly just to the lateral edge of the acromion.

    Arthroscopic image from lateral portal showing edge of rotator cuff tendon (RC) with the articular cartilage of the humeral (HH) and the bony footprint of the greater tuberosity (FP).

    External image showing position of white needle placed to optimise the superolateral portal.

    Ascertain position of superolateral portal with percutaneous needle placement to optimise angle for medial anchor placement.Arthroscopic image showing position of white needle down to bony footprint in the mid-section of the full thickness tear. The needle should be placed lateral to the lateral edge of the acromion and aim to strike perpendicular to the medial aspect of the prepared greater tuberosity footprint as shown. This will allow the medial anchor to be placed in good bone of the proximal humerus at an angle that avoids breaching the articular surface of the humeral head.

    External image showing white needle removed and scalpel blade being used to make stab incision for superolateral portal.

    Use scalpel make stab incision for superolateral portal.Scalpel is advanced to create the superolateral portal. There are no structures at risk from this ‘portal on demand’.

    Arthroscopic image showing a tip of No. 11 scalpel blade under direct vision approaching the bony footprint of the greater tuberosity.

    Create hole for medial anchor using awl punch on medial edge of footprint in centre of rotator cuff tear.The Arthrex arthroscopic awl punch is inserted from the superolateral portal to make the hole for medial anchor placement.

    Tip of awl is placed on the medial aspect of the bony footprint just at the edge of the articular cartilage of the humeral head.

    Once the position of the awl is optimised then this is impacted using a small mallet to advance it into the bone.

    Arthroscopic imaging showing advancing awl down to cover the laser mark FT for the use of an Arthrex fully threaded (FT) Bio-Corkscrew FT anchor.
    The SL line would be used for a SwivelLock anchor.
    Make sure that the awl is in the body of the metaphyseal bone and not too angled risking penetrating the articular surface of the humeral head or even not too lateral creating a thin bone bridge which may fracture. This can be assessed by the resistance of the awl to being struck by the mallet.

    Creation of hole for medial anchorArthroscopic image showing awl removed and position of the hole created for the anchor to be placed.

    This shows the Bio-Corkscrew FT anchor removed from the package. It is a “screw-in” device, pre-loaded with two No 2 Fibrewire sutures.
    Here a decision has been made to use a Bio-Corkscrew FT anchor which is 5.5 x 14.7 mms in dimensions.

    Bio-Corkscrew anchor is then placed through the superolateral portal.

    Insert Arthrex 5.5mm BioCorkscrew-FT anchor into prepared hole on medial footprint.Arthroscopic image showing positioning of the anchor within the created hole at the edge of the articular surface and medial aspect of the bony footprint.

    The anchor is screwed into the bone.

    Arthroscopic image showing anchor being screwed into the bone. Note the circumferential black line on the introducer.

    The anchor fully seated in position as the circumferential black line on the introducer has advanced into the bone hole.

    Unwrap the suture material from its attachment to the outside of the blue anchor handle.

    Once anchor in position remove insertion handle.Once the sutures are released from the handle, the insertion handle can be pulled directly back out of the shoulder with a sharp tug leaving the anchor and sutures in place.
    At this stage gently traction on the sutures confirms that the anchor is strongly fixed in the bone.

    Arthroscopic image confirming anchor seated in position and sutures exiting from the hole in the bone.
    Two different colours of Fibrewire suture material are seen – one blue and one white with black stripes.

    Arthroscopic image showing position of the switching stick placed from the posterior portal and lying on top of the rotator cuff, as viewed from lateral. This allows accurate re-positioning of the arthroscope through the posterior soft tissues.

    Operation – 4

    Extend lateral portal size with scalpel to accommodate 8.25mm cannula.The arthroscopic sheath has been passed across the switching stick and allows the arthroscope to be re-positioned in the posterior portal. Sutures can be seen exiting from the superolateral portal. Scalpel blade is used to extend the lateral portal to accommodate an 8.25mm cannula which will facilitate passage and management of the sutures avoiding soft tissue bridges. The use of the cannula also protects the deltoid muscle from multiple passage of the Scorpion suture passing instrument in and out od the subacromial space.

    Place switching stick into lateral portal

    Tip of switching stick entering lateral portal

    Insert large 8.25mm cannula to lateral portal over switching stick.An Arthrex 8.25mm cannula loaded on cannulated gold handle inserter is passed over the switching stick.

    Screw cannula into lateral portal

    Tip of cannulated inserter passing into subacromial space through the lateral portal

    Cannula in position in lateral portal and metal inserter and switching stick removed

    Arthroscopic image from posterior showing mouth of cannula in lateral portal facing sutures from medial anchor

    Take suture grasper from Arthrex shoulder instruments

    Place suture grasper into lateral cannula

    Organise sutures from medial anchor using suture retriever from lateral cannula.Use suture grasper to separate blue and white/black sutures and allocate one colour to be the anterior pair and the others to be posterior.
    Here white/black have been taken anteriorly.

    Using the suture grasper retrieve one limb of the anterior white/black suture out through the lateral cannula. Take care to closely observe the arthroscopic image to ensure the correct limb of suture is being taken out of the cannula and that the suture is not unloaded from the anchor.

    Retrieve first, most anterior, suture from lateral cannula.First limb of suture withdrawn from lateral cannula using suture retriever.

    Discard suture retriever and use fingers to gently pull suture from cannula.

    First suture out of the lateral cannula

    Load first suture into Scorpion suture passer.Take the Arthrex Scorpion FastPass suture passing instrument and load with the end of the first suture from the lateral cannula.

    With gentle traction on the suture, insert the Scorpion down the cannula.

    Pass first anterior suture through tendon using Scorpion.Open the jaws of the Scorpion in the subacromial space and take a good bite of tendon from the anterior part of the tear

    Squeezing the Scorpion handle halfway grasps the tendon tissue. Confirm desired position in anterior aspect of rotator cuff tear and gently turn instrument towards the arthroscope so that the trapdoor can be seen clearly

    Further and full squeeze of Scorpion handle advances the needle which passes the suture through the tendon and into the instrument’s trapdoor to capture it.

    Release of the Scorpion handle withdraws the needle and closes the trapdoor capturing the suture loop passed through the rotator cuff tendon.

    Release bite of tendon and withdrawal of the Scorpion from lateral cannula pulls the suture through the tendon seen here caught in the trapdoor.

    Remove Scorpion from cannula. A further single full squeeze of the handle releases the suture from the trapdoor

    Discard Scorpion and pull suture from cannula

    Take suture retriever again and insert into cannula past first suture

    Operation – 5

    Retrieve second suture from lateral cannula.In the subacromial space take the second white/black suture and remove from cannula

    Retrieve the second suture from the lateral cannula

    Take first suture, already passed through tendon, out of superolateral portal.Insert the suture retriever into the superolateral portal. Both white/black sutures seen in the lateral cannula

    From the superolateral portal retrieve the first suture already passed through the rotator cuff tendon

    First suture exiting superolateral portal

    Load second suture on Scorpion.First suture being taken out of the superolateral portal and second suture in lateral cannula being loaded onto Scorpion

    Insert Scorpion with second suture down cannula

    Advance Sorpion into subacromial space and pass in front of pair of blue sutures

    Pass second suture through torn tendon just behind first anterior most suture and approximately in middle of tear.Open Sorpion jaws and take second bite of tendon through tear. Position of second suture should be just behind first and most anterior suture in approximately the middle of the tear

    Squeeze the Scorpion handle halfway to grasp the tendon and rotate the instrument towards the arthroscope to be able to see the trapdoor

    Once desired position is confirmed further and full squeeze of the Scorpion handle advances the needle which passes the second sutures through the tendon

    Release of the Sorpion handle withdraws the needle leaving the suture caught in the trapdoor

    Remove the Scorpion and second suture from the lateral cannula repeating the process of the first suture

    Repeat the process for the third and fourth sutures. Retrieve unpassed sutures laterally and take passed sutures through superolateral portal. Load unpassed sutures onto Scorpion and pass through tendon each posterior to the previous.Retrieve the first of the posterior blue sutures

    First blue suture exiting lateral cannula

    Pull first blue suture from lateral cannula once again ensuring that the suture is not unloaded from the anchor

    This shows the current position of the sutures. Both white/black sutures have been passed through the torn tendon. The first anterior one is exiting the superolateral portal (SLP) and the second one is still in the lateral cannula (LC). Neither blue suture has been passed through the tendon yet. The third suture (anterior of the posterior blue pair) is exiting the cannula ready to be loaded on the Scorpion and the final fourth and most posterior suture remains in the superolateral portal.

    External view of one of each blue and white/black sutures exiting each of superolateral and lateral (cannula) portals

    Insert suture retriever into superolateral portal and retrieve second suture

    Capture second suture (posterior white/black) which has been passed through the tendon

    Remove second suture from superolateral portal leaving blue suture in lateral cannula

    Load third suture onto Scorpion as previously and insert through lateral cannula. Take a bite of tendon through the tear

    Pass third suture through torn tendon.Confirm desired position of third suture just posterior to mid-tear

    Repeating the same sequence as for the first two sutures, full squeeze of Scorpion handle advances the needle and passes the suture through the tendon

    Release and remove Scorpion from cannula

    Operation – 6

    Pass fourth and final suture through torn tendon.Having passed the third suture, repeat the process of retrieving the fourth and final suture from the cannula then taking the third suture out of the superolateral portal. Here using the foot pedal for the Spider 2 the arm can be manoeuvred with internal rotation to facilitate access to the posterior aspect of the rotator cuff tear for placement of the final suture.

    Here the Scorpion passes the second blue suture, the fourth and final one, into the posterior rotator cuff tear

    The final suture is caught in the Scorpion trapdoor and removed from the lateral cannula

    Posterior arthroscopic view of all four sutures passed through the rotator cuff tendon

    Insert the suture retriever into the cannula past the final suture which is already exiting

    When all four sutures have been passed through the torn tendon take all through the lateral cannula.Capture the three anterior sutures and remove from the cannula

    Remove retriever from the cannula

    All four suture limbs are now pulled through the lateral cannula

    Insert the suture retriever into the superolateral portal

    Retrieve middle pair of sutures through superolateral portal together to avoid creating a tissue bridge between the suture limbs.Capture the middle two sutures – the second and third passed which are the posterior white/black and anterior blue.

    Retrieve this middle pair of sutures

    Take the middle pair of sutures out through the superolateral portal

    Arthroscopic image showing the middle pair of sutures exiting the superolateral portal and outer pair in the lateral cannula

    Pull on each of the sutures left in the lateral cannula to equalise the lengths bringing the ends together which also ensures the sutures are running freely through the anchor and tendon tissue

    Tie middle pair of sutures together extracorporally outside the shoulder and cut off excess suture with scalpel blade.By tying the middle pair of sutures here seen over the assistant’s finger, the blue and white/black sutures then become one continuum

    Use a simple surgeon’s knot to securely tie the superolateral pair of sutures together

    Complete the knot with three throws

    Tighten knot down

    Cut excess suture tails with a scalpel blade

    Now pull on the suture limbs in the lateral cannula and the tied knot of the superolateral sutures advances into that portal

    Traction on lateral cannula sutures pulls the tied knot into the superolateral portal.Gently pull sequentially on each lateral suture to pull the knot into the superolateral portal

    Inspect arthroscopically to watch the knot enter the subacromial space from the superolateral portal

    Pull down medial sutures to repair medial footprint.Further traction on the lateral sutures pulls the knot down onto the medial rotator cuff to snug the prepared tendon onto the anchor at the medial footprint by the articular margin

    Load lateral cannula sutures onto Arthrex 5.5mm BioSvivelock-C anchor.Take an Arthrex 5.5mm BioSwivelock-C anchor and load the two lateral sutures into the tip eyelet using the wire suture passer on the anchor

    Removing the orange handle of the wire suture passer pulls the sutures through the tip eyelet of the anchor

    Operation – 7

    Pull the sutures through the anchor tip eyelet

    Adjust arm position if needed to access lateral greater tuberosity in sub-deltoid space.Using the Spider 2 pedal the arm can be moved to abduct the shoulder slightly

    Place the Werewolf ablation wand into the lateral cannula

    Clear soft tissue from the lateral humerus and subdeltoid space to ascertain optimal position for the lateral anchor

    Take the awl punch. Note the anchor loaded on the sutures and a clip in place on the sutures to prevent the anchor falling off

    Use awl punch to make hole for lateral anchor in line with centre of rotator cuff tear.Insert the awl into the lateral cannula

    Tip of the awl enters the subacromial space from the lateral cannula and finds position for lateral anchor approximately 1cm below the lateral edge of the prepared bony footprint of the greater tuberosity in line with the centre of the rotator cuff tear

    The cortical bone of the proximal lateral humerus at this site is very thin and often firm pressure on the awl will be sufficient to advance in into the bone. Occasionally tapping with the mallet is required in harder bone

    The awl is advanced into the bone to cover the laser mark SL for the SwivelLock anchor. Note outer pair of sutures (one white/black anteriorly and other blue posteriorly) exiting the cannula around the awl

    Insert lateral anchor down cannula and screw into lateral hole with tension on sutures to pull lateral rotator cuff edge down to edge of prepared bony footprint.Remove the awl from the cannula then pulling the clip to tension the sutures, slide the anchor down the sutures into the cannula

    Advance the anchor into the subacromial space. Note the flat ‘square’ paddle of the blue handle just below the pear-shaped end of the introducer handle.

    Watch the monitor as the tip eyelet of the anchor enters the subacromial space down the lateral cannula

    Advance the anchor handle to position the tip eyelet into the lateral hole.

    Confirm the position of the tip eyelet into the lateral hole

    Push the anchor handle to advance the eyelet into the bone until the body of the anchor appears from the cannula and sits up against the bone. Pull on each limb of the sutures to pull them down over the lateral edge of the rotator cuff tear tissue

    Once the anchor is in position and the sutures tensioned to pull the tendon tissue down, hold the flat square paddle on the anchor handle and ask the assistant to screw the pear-shaped handle clockwise to screw the anchor into the bone – “hold the square and turn the pear”

    Watch the anchor advancing as it is screwed into the bone

    Advance the anchor until it disappears and the bone handle is flush with the bone

    Unwind the core sutures, which hold the tip eyelet onto the introducer, from the end of the pear-shaped handle

    With a firm tug pull the anchor introducer handle directly back out of the cannula

    Removing the handle leaves the core suture which can also be simply pulled out of the cannula

    When anchor fully seated and insertion handle removed, cut the lateral sutures to complete the repair.Place the ends of the final repair sutures from the lateral anchor through the top of the Arthrex suture cutter and slide the instrument down the sutures into the lateral cannula

    Advance the suture cutter down to where the sutures enter the bone

    Squeeze grip the handle of the suture cutter to cut the sutures flush with the bone. The rotator cuff repair is complete.

    Start subacromial decompression using high speed shaver from lateral cannula for anterior acromioplasty.The shaver is placed into the lateral cannula

    Operation – 8

    The Smith and Nephew 5.5mm Bone Cutter shaver blade is used on fast forward. Start to resect bone from the anterolateral edge of the acromion.

    Resect bone equal to the width of the shaver from lateral (L) to medial (M)

    Continue advancing the shaver from lateral to medial across the front of the acromion until a flat surface is achieved

    Swap the shaver for the ablation wand to clear any residual periosteum from the resected acromial margins and coagulate any bleeding points

    Now remove the arthroscope from posterior and insert down lateral cannula

    Rotate the light source on the arthroscope to inspect around the subacromial space

    Identify the recently resected anterior edge of the acromion (A) above and the newly repaired rotator cuff (RC) below

    With the ablation wand in the posterior portal clear the posterior subacromial bursa and any residual soft tissue from the acromion

    Change arthroscope from posterior portal to the lateral cannula to inspect rotator cuff repair.Rotate light source to look down on rotator cuff and inspect final repair. Note the medial knot (K) can just be seen at the top of the image. The outer pair of sutures can be seen with blue limb posteriorly (P) and white/black limb anteriorly (A)

    At this juncture it worth remembering how the tear appeared from the lateral view before it was repaired to compare with the repair performed.

    Look down more laterally to see the convergence of the outer pair of sutures to the lateral anchor (LA) and how they reduce the rotator cuff edge (RCE) to the bony footprint

    Place shaver into posterior portal to complete decompression with posterior cutting block acromioplasty.Having inspected rotator cuff repair from lateral, place shaver into posterior portal

    Smith and Nephew 5.5mm Bone Cutter shaver (S) tip in the subacromial space underneath the acromion (A) above the rotator cuff (RC)

    Complete the acromioplasty by resecting bone using the shaver on fast forward mode starting medially next to the acromioclavicular joint (ACJ) and sweeping across under the acromion towards the arthroscope laterally. This is the posterior cutting block technique.

    View from lateral of the final acromioplasty (A) with smooth flat resected bone above and the repaired rotator cuff below showing the medial knot (K) and anterior white/black suture (WBS)

    Final inspection of rotator cuff repair confirming watertight closure of the full thickness hole in the supraspinatus tendon insertion

    With all instruments, arthroscope and cannula removed, the three portals are seen – posterior (P), superolateral (SL) and lateral (L)

    Close skin of portals with simple Nylon stitches.3/0 Nylon suture is used to close the skin of the arthroscopic portals

    Simple stitch to close the superolateral portal

    Simple stitch to close the posterior portal

    Horizontal mattress stitch to close the larger lateral portal that accommodated the 8.25mm cannula

    Apply adhesive absorbant dressings to cover portals.Adhesive absorbant dressings are applied to cover the portal sites

    Add an absorbant pad fixed with adhesive tape strips.An absorbant SurgiPad is applied over the simple dressings

    The SurgiPad is fixed using broad strips of adhesive Mefix tape

    Final view of temporary bulky absorbant dressings

    Operation – 9

    Apply standard sling to rest shoulder.Simple Polysling is applied to the operated arm to rest the shoulder in neutral internal rotation with the elbow flexed at right angle

    Post Operative

    The aims of rehabilitation are to protect the repair in the early stages and to maximally optimise function.
    General Points
     Do not push through pain – remember pain inhibits rotator cuff control
     Do not sacrifice quality of movement for ROM
     Remember the pathophysiology of the repaired tendon is probably degenerative and needsto be considered when progressing rehabilitationImmobilisation
     Patient to wear sling for 6 weeks, it can be removed to perform exercises as instructed by physiotherapist

    Post Operative
    0-4weeks

    Pendular exercises
    Active assisted ER to 300
    Active assisted elevation as comfort allows – consider use of table slides or walk backs
    4-6 weeks

    Gradually wean out of sling – light activities only (weight of a cup of tea within the field of vision, short lever)
    Exercises stay the same until 6 weeks
     Active assisted ER to 300
     Active assisted elevation as comfort allows – consider use of tableslides or walk backs
    6 weeks

    Gradually increase ER
    As ER increases gradually increase Elevation ROM
    Active assisted exercises progressing to active exercises – utilise short lever, supine & closed kinetic chain if appropriate
    No long lever open chain exercises until 12 weeks
    12 weeks+

    Isometrics in variable starting positions progressing to resisted through range strengthening
    Functional Milestones
    Activity

    Time scales
    Driving

    See general principles of rehabilitation
    Swimming

    12 weeks+
    Golf

    12 weeks+

    Recommended Reading

    Mid-term clinical and sonographic outcome of arthroscopic repair of the rotator cuff.
    O Levy, B Venkateswaran, T Even, M Ravenscroft, S Copeland.
    J Bone Joint Surg Br. Vol 90-B, Issue 10, October 1, 2008, pages 1341-1347
    Prospective study to assess mid-term clinical results following arthroscopic repair of the rotator cuff
    102/115 available for follow up mean 35.8 months (24-73)
    Mean age 57.3 (23-78) with statistically significant increase in size of tear with increasing age
    Mean preop Constant score was 41.4 which improved to 84.5.
    Significant inverse association observed between size of tear and postop Constant score with patients having smaller tears attaining higher Constant scores
    78.4% able to resume occupations and 82.4% returned to leisure activities
    Patients with recurrent tears experienced a mean improvement of 31.6
    Patient satisfaction was high in 92% cases irrespective of outcome of Constant score

    Outcomes of single-row and double-row arthroscopic rotator cuff repair: a systematic review.
    P Saridakis, G Jones.
    J Bone Joint Surg Am. 2010 Mar;92(3):732-42
    apparent benefit of structural healing with double-row fixation as opposed to singe-row
    little evidence to support any functional differences between the two techniques except perhaps with large or massive tears
    decision making should consider risk-reward analysis of age, functional demands and other quality of life issues
    double-row fixation may result in improved structural healing in some patients depending on size of the tear

    Factors affecting healing rates after Arthroscopic Double-Row Rotator Cuff Repair
    RZ Tashjian, AM Hollins, H-M Kim, SA Teefey, WD Middleton, K Steger-May, LM Galatz, K Yamaguchi
    Am J Sports Med. 2010 Dec;38(12):2435-42
    49 shoulders evaluated with ultrasound minimum 6 months after double row arthroscopic rotator cuff repair
    Older age and longer duration of follow-up correlate with poorer tendon healing
    VAS pain score, movement, ASES all significant improvement from baseline repair
    Biological limitation at repair site appears most important factor influencing tendon healing even after maximising repair biomechanics strength with a double-row construct

    BESS/BOA Patient Care Pathways – Subacromial shoulder pain
    R Kulkarni, J Gibson, P Brownson, M Thomas, A Rangan, A Carr, J Rees
    Shoulder & Elbow 2015. Vol 7(2): 135-143
    Current British best practice evidence based guidelines for the management of subacromial shoulder pain which includes rotator cuff tears
    Excellent clearly written document describing all aspects of subacromial shoulder pain including the surgical recommendations for repair

    Costs, quality of life and cost-effectiveness of arthroscopic and open repair for rotator cuff tears – an economic evaluation alongside the UKUFF trial
    J Murphy, A Gray, C Cooper, D Cooper, C Ramsay, A Carr
    Bone Joint J 2016;98-B:1648-55
    No significant overall difference in the use or cost of resources or quality fo life between arthroscopic and open management
    Uncertainty about which strategy was most cost-effective

    Effectiveness of open and arthroscopic rotator cuff repair (UKUFF), a randomised controlled trial.
    A Carr, C Cooper, MK Campbell, JL Rees, J Moser, DJ Beard, R Fitzpatrick, A Gray, J Dawson, J Murphy, H Bruhn, D Cooper, C Ramsay
    Bone Joint J 2017;99-B:107-15
    273 patients recruited to a randomised comparison trail (136 to arthroscopic surgery and 137 to open surgery) from 19 teaching and general hospitals in UK
    Surgeons used their usual preferred method of repair
    Oxford Shoulder Score (OSS) two years postop was primary outcome measure
    Imaging of shoulder performed one year after surgery
    OSS improved from 26.3 to 41.7 at 2 years for arthroscopic group and from 25 to 41.5 for open surgery
    Rate of re-tear not significantly different between the two groups. Healed repairs had most improved OSS
    No evidence of difference in effectiveness between open and arthroscopic repair of rotator cuff tears
    The rate of re-tear is high in both groups for all sizes of tear and ages and this adversely affects the outcome

    Cost-effectiveness and satisfaction following arthroscopic rotator cuff repair – does age matter?
    JA Nicholson, HKC Searle, D MacDonald, J McBirnie
    Bone Joint J 2019;101-B:860-866
    112 patients prospectively monitored for 2 years after arthroscopic rotator cuff repair using DASH, OSS and EQ-5D.
    92 patients completed follow-up with mean age 59.5
    Significant improvements in mean DASH and OSS scores
    Functional improvements were maintained with no significant change between one and two years postoperatively
    Arthroscopic rotator cuff repair results in excellent patient satisfaction and cost-effectiveness, regardless of age

    Surgical repair versus conservative treatment and subacromial decompression for the treatment of rotator cuff tears – a meta-analysis of randomised trials
    C Schemitsch, J Chabal, M Vincente, L Nowak, P-H Flurin, F Lambers Heerspink, P Henry, A Nauth
    Bone Joint J 2019;101-B:1100-1106
    Purpose to compare effectiveness of surgical repair to conservative treatment and subacromial decompression for the treatment of chronic/degenerative tears of the rotator cuff
    Systematic review included six studies
    Surgical repair resulted in a statistically better Constant-Murley Score at one year compared with conservative treatment and subacromial decompression alone
    In the conservatively treated group, 11.9% of patients eventually crossed over to surgical repair
    Results show that surgical repair results in significantly improved outcomes when compared with either conservative treatment or subacromial decompression alone for degenerative rotator cuff tears in older patients
    Magnitude of the difference in outcomes may be high allowing surgeons to be judicious in choosing those patients who are most likely to benefit from surgery

    Reference

    • orthoracle.com

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