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Technique: Arthroscopic rotator cuff repair with Arthrex Speedbridge

    Overview

    Learn the Arthroscopic rotator cuff repair with Arthrex Speedbridge 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 with Arthrex Speedbridge 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, experience 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 medium to large 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. I use the Arthrex shoulder repair instruments and implants during this case. I find that this system has been designed to make operations easier by engineers and surgeons working together. The set of instruments covers all bases in terms of having something that helps in every situation and the range of implants allows flexibility between types and sizes of anchors and suture material. In this case I use the 4.75 and 5.5 BioSwivelock C anchors with FiberTape suture material.
    Readers will also find of interest Mark Crowthers’ related techniques:
    Arthroscopic subacromial decompression
    Arthroscopic rotator cuff repair using modified Arthrex suture-bridge technique

    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. I use this technique for a medium to large sized tear of supraspinatus and/or infraspinatus. The same technique could be used for subscapularis tendon however this is less common. Usually acute tears are traumatic in nature whereas chronic tears are more likely to be degenerate.
    Symptoms and Examination
    Patients present with pain, dysfunction and weakness in their effected shoulder. There may be 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 scapula in the supra- and infraspinatus fossae. Examination should ascertain whether the patient has maintained a full range of motion and also strength with formal testing of rotator cuff strength. Resistance to shoulder elevation in the plane of the scapula 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 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. Knots can be tied in the suture materials attached to the anchors or knotless techniques, such as described in this case, can be used.
    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. In the immediate postoperative period, bleeding from the resection acromial bone will bathe the repair in nutritious blood clot theoretically promoting healing of tendon to bone.
    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 left 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 left shoulder. This shows a slight curve to the acromion process of the scapular and previously noted aged related degenerate change in the acromioclavicular joint but little else of significance.

    Coronal section of MRI scan left shoulder.
    This shows the humeral head (HH) of the glenohumeral joint and deltoid muscle (D) wrapping the shoulder. The supraspinatus muscle (SSp) looks normal but following it down to the tendinous insertion to the footprint of the humeral head great tuberosity (GT) reveals a gap which is a full thickness tear of the rotator cuff (RCT).

    Transverse section of MRI scan left shoulder.
    This image shows the humeral head (HH) and deltoid muscle (D) but also the rotator cuff tear of supraspinatus (RCT).

    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. First clear chlorhexidine solution is used to prepare the hand which is then covered in a cloth stockinette. Then 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.
    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

    The blue material arm glove attachment is secured with the Velcro straps

    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.

    The setup is complete showing the arthroscopic stack (AS) including the monitor and image capture system and arthroscopy fluid bags (FB). The arm is secured in the Spider 2 arm positioner (SAP) and the sterile drape (D) with its fluid capture bag.
    I have the arthroscope (A) with its light lead and the fluid tubing attached to the drape behind the patient and the shaver (SHP) attached to the drape over the patient’s waist.

    The instruments used often have the option of either button hand controls or floor pedals. Here the array of pedal options are shown: shaver (Sh) with left anticlockwise, centre oscillate, right clockwise; Spider (Sp) release; wand (W) with yellow for ablation and blue for coagulation; and the pump (P) controls with red being lavage which transiently increases the fluid pressure.

    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 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.

    The 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. The rotator interval is the capsule spanning the area between the upper border of subscapularis anteriorly and the anterior border of supraspinatus superiorly.

    Here a white needle is placed into the anterosuperior aspect of the shoulder to release an air bubble within the joint.

    The needle bevel seen here beneath the long head of biceps tendon (LHB) in the rotator interval (RI).

    Humeral head (HH), glenoid (G) and anterior glenoid labrum (AGL) are inspected from posterior. This confirms that there is no evidence of arthritis on the joint surface.

    Identify the articular surface of the supraspinatus rotator cuff tear.Rotating the light lead allows inspection of the top of the Humeral Head (HH) where 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 and it 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. Usually the lateral portal will be 3cm down from the tip of the acromion.

    View directly with the arthroscope to see the bevel of the needle come through the rotator cuff tear into the glenohumeral joint which confirms the position chosen is appropriate for the lateral portal. A number 11 blade traces the path of the needle to create the portal.

    Operation – 2

    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.

    On the arthroscopic view watch the tip of the scalpel blade carefully advanced into the tear, avoiding damage to the tendon and articular surface of the humeral head.

    Having incised the skin the scalpel is advanced through the subacromial space and through the tear as observed with the arthroscope.

    Having removed the scalpel, a jet of water can be seen exiting the lateral portal confirming communication with the water source, the arthroscope in the glenohumeral joint.

    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.

    Introduce the ablation wand into the glenohumeral joint via lateral portal and through rotator cuff tear.

    Prepare torn edge of rotator cuff tendon and its bony footprint on the greater 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.

    Using the Spider foot pedal to release the arm holder allows changing the position of the arm and shoulder to optimise the view of the tear.

    Once the position of the shoulder is optimised preparation can continue. Here the radiofrequency wand is being used in ablation mode with the yellow floor pedal.

    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 showing arthroscope removed from the posterior portal and trocar placed within the sheath.

    Move arthroscope from glenohumeral joint into subacromial space.Sheath and trocar are placed into the lateral portal and is now advanced into the subacromial space. This should be an easy passage into the capacious space beneath the acromion superiorly through the deltoid muscle laterally and anteriorly with humeral head below. In the presence of a full thickness rotator cuff tear the subacromial space communicates with the glenohumeral joint through the torn tendon. If the rotator cuff was in tact then the two spaces are separate.

    Pass arthroscope into sheath into the subacromial space.

    The 30 degree arthroscope lens is tilted away from the light source so rotating the light lead changes the view seen on the monitor. Here the lead is rotated so the source is directly upwards hence the view will look 30 degrees downwards to inspect the rotator cuff tear.

    Inspect the rotator cuff tear from lateral in the subacromial space.From the lateral portal the subacromial bursal surface of the rotator cuff tear (RCT) is inspected. Note the white articular cartilage of the humeral head (HH) and the already prepared bone of the greater tuberosity footprint (FP). This footprint area is where the supraspinatus tendon would normally be inserted and from where it has torn or avulsed. If the rotator cuff was intact this area would not be exposed at all and hence would not be visible.

    This is a schematic illustration of the torn tendon end and the bony footprint of the great tuberosity. This will be added to intermittently during the procedure to facilitate the clinical arthroscopic images.

    Rotating the light lead 180 degrees so the source is directly downwards allows inspection of the coracoacromial ligament on the undersurface of the acromion in the roof of the subacromial space.

    Arthroscopic view of the coracoacromial ligament (CAL) on the undersurface of the acromion above the rotator cuff tear (RCT).

    Looking posteriorly in the subacromial space reveals a bursal plica (BP) above the rotator cuff tendon (RC). This plica can be resected with the shaver.

    The shaver is placed into the subacromial space from the posterior portal to resect the bursal plica and further prepare the edge of the rotator cuff tear.

    Remove the shaver from the posterior portal and replace it with the switching stick.

    The switching stick is advanced from the posterior portal and viewed in the subacromial space on top of the rotator cuff tear (RCT). The switching stick is used to allow quick and easy passage of the arthroscope sheath into an accurate position identified under direct vision as shown avoiding unnecessary damage to soft tissues through which it passes, particularly the deltoid muscle.

    Remove the arthroscope from the lateral portal and disconnect the sheath. Pass the sheath over the switching stick in the posterior portal.

    Operation – 3

    Insert the arthroscope into the sheath in the posterior portal.

    Connect the arthroscope to the sheath in the posterior portal in the subacromial space.

    Inspect subacromial space to identify coracoacromial ligament.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.

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

    Insertion of the radio frequency wand into the lateral portal and into the subacromial space allows clearance of soft tissue bursal material here seen using the yellow pedal for ablation.

    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).

    Detach coracoacromial ligament from acromion and coracoid.Arthroscopic image of the subacromial space showing the mobilised coracoacromial ligament (CAL) from the acromion above.

    Take the arthroscopic grasper (G).

    Insert the arthroscopic grasper into the subacromial space through the lateral portal.

    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.

    Remove the resected coracoacromial ligament from the lateral portal.The resected coracoacromial ligament is removed from the lateral portal.

    Close up of the resected coracoacromial ligament tissue.

    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.

    Assess mobility of the rotator cuff tendon following its preparation.Insert the cuff grasper to the lateral portal.

    Grasp the edge of the rotator cuff tear and assess the mobility and quality of the tendon tissue.

    Pull the edge of the torn tendon down to the footprint insertion. This confirms that the tendon tissue is mobile and reducible to the site from which it’s torn. If that hadn’t been the case then further releases of the soft tissues should be performed. Perilabral and subacromial releases break down soft tissue adhesions and allow mobilisation of the tendon edge.

    Plan the position of a superolateral portal with percutaneous needle placement to optimise angle for medial anchor placement.External image showing position of arthroscope in the posterior portal. A white hypodermic needle is inserted superiorly just to the lateral edge of the acromion.

    Arthroscopic image showing position of white needle towards the 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 position of white needle placed prior to making the superolateral portal.

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

    Watch the tip of the scalpel blade (T) enter the subacromial space just lateral to the edge of the acromion (Acr). The blade is only passing through skin, fat and deltoid muscle at this site. I aim to minimise damage to the muscle by advancing the blade in line with the muscle fibres ie with the scalpel blade perpendicular to the lateral edge of the acromion.

    Advance the scalpel into the subacromial space creating the superolateral portal.

    Place the switching stick into the lateral portal.

    Watch the switching stick enter the lateral portal.

    Operation – 4

    Choose the medial anchorFor the medial anchor I use the Arthrex 4.75mm biocomposite BioSwivelock C. This is a screw-in anchor which needs to be loaded with suture material.

    Take FiberTape suture materialTo load the medial anchor I use Arthrex FiberTape which is a 2mm braided polyblend tape suture material. I use this for this technique when I have confirmed the tendon tissue to be repaired is good consistency and mobile.

    Load the anchor with the FiberTapeHolding the anchor introducer handle, take the thin end of the FiberTape.

    Pass the thin end of the FiberTape into the wire loop of the anchor threader

    Detach the orange handle of the suture threader and pull the wire loop through the eyelet at the end of the anchor

    This pulls the FiberTape into the anchor eyelet. Pull the tape through so the ends are of equal length hence the eyelet is in the middle of the length of the tape.

    Place the arthroscope into the lateral portal by placing the sheath over the switching stick.

    Take the awl (A) from the Arthrex shoulder repair instruments. This is used to make the hole in the bone into which the anchor is screwed.

    Place the awl into the superolateral portal.

    Inspecting from lateral, advance the awl (A) down to the bony footprint (FP) of the greater tuberosity. Here the position of the anteromedial anchor is selected just lateral to the articular cartilage of the humeral head (HH) just behind the intact anterior rotator cuff insertion (RCI). Having assessed the extent of the tear I want to use two medial anchors. They should be adequately spaced to avoid a narrow ‘bone bridge’ between them and allow them to have a good fix in the bone. The awl should be inserted perpendicular to the bone to create the hole to further optimise the fixation of the anchor in the bone.

    Make anteromedial anchor hole with the awlWhen optimal position for the anteromedial anchor is established, take a toffee mallet (TM) and use it to tap the awl which is held firm against the bone.

    Inspect the monitor to watch the awl advancing. There are two laser lines on the awl shaft – the first is FT for use with the fully-threaded Biocorkscrew anchor (not being used in this case) and the second SL for the Swivelock anchor as being used here.

    Continue firm tapping of the mallet on the end of the awl to advance it into the bone.

    Continue impacting the awl and advancing it into the bone until the SL line is covered

    Remove the awl from the superolateral portal

    Take the Arthrex 4.75 Bioswivelock C anchor loaded with the FiberTape and keeping the tape taut insert the anchor into the superolateral portal.

    From the superolateral portal advance the loaded anchor so the eyelet enters the prepared anteromedial hole.

    Push the green handle of the anchor introducer to advance the anchor into the hole. Note the pear-shaped end of the introducer.

    Watch as the body of the anchor (BA) comes to sit at the mouth of the hole

    When the body of the anchor is in position hold the flat square paddle on the green anchor introducer and turn the pear-shaped end of the introducer clockwise to screw the anchor into the bone. Remember to “Hold the square and turn the pear“

    Watch as the anchor screws into the bone

    Continue screwing the anchor into the bone.

    Watch the monitor to confirm when the anchor is fully buried in the bone.

    With the anchor fully seated in the bone, unwind the core suture from the circumference of the pear-shaped handle. This suture runs down the inside of the anchor introducer and holds the eyelet of the anchor to the end of the introducer.

    Once the core suture is fully unwound from the handle the green introducer the whole introducer can be pulled out of the superolateral portal.

    Operation – 5

    With a firm tug the green anchor introducer is pulled from the superolateral portal

    That leaves the core suture in the superolateral portal in addition to the FiberTapes that are fixed into the bone with the anchor. Pull one limb of the core suture to remove completely.

    Inspect the arthroscope to see the anteromedial anchor fully seated in the bone with the two limbs of FiberTape emanating from the hole.

    A gentle pull on the FiberTapes confirms that the anchor is strongly fixed in the bone. If the anchor pulled out due to soft bone then a 5.5 anchor could be used in the same hole.

    Repeat the process to insert the second anchor in the posteromedial position. Insert the awl through the superolateral portal.

    Inspect from lateral as the awl (A) is positioned for the second anchor hole on the posteromedial aspect of the bony footprint (FP) just lateral to the articular cartilage of the humeral head (HH). The FiberTapes (FT) from the anteromedial anchor can be seen on the left of the screen.

    External view of the awl positioned in the superolateral portal ready to be tapped by the mallet.

    Impacting the awl with the mallet advances it into the bone. Here yellow bubbles of bone marrow fat can be seen emanating from around the awl.

    Once the SL line has been reached withdraw the awl to reveal the second hole.

    Take a second Arthrex 4.75 BioSwivelock C anchor loaded with Fibertape and via the superolateral portal insert the implant into the posteromedial hole.

    Advance the anchor into the hole until the body of the anchor sits at the mouth of the hole.

    Screw the anchor into the hole and again “Hold the square and turn the pear”.

    Watch as the body of the anchor screws into the hole.

    Remove the anchor introducer handle leaving the anchor firmly fixed in the bone. Here FiberTapes can be seen from anteromedial (AM) and posteromedial (PM) anchors.

    The schematic shows the medial anchors inserted on the bony footprint. The anchor on the left with the blue FiberTape is anterior and the other on the right with the green FiberTape is posterior. The next few cartoons will illustrate the sequence of events of passing the tapes to carry out the repair.

    Using the Scorpion suture passer all four limbs of Fibertape are passed through the tendon.

    Organise the tapes and take the anterior pair ie the anterior limb of tape from each the anterior and posterior medial anchor.

    Taking the chosen anterolateral anchor, load it with the anterior pair of tapes.

    Take the posterior pair of tapes ie the posterior limb of tape from each the anterior and posterior medial anchor, and load them into a second lateral anchor.

    Pull on the tapes sequentially to reduce the tendon edge down to the prepared bony footprint of the greater tuberosity and then fix the lateral anchors in the bone.

    The illustation of the final repair. The dotted lines indicate the tapes passing from the medial anchors through the tendon. The black dots indicate the four anchors buried in the great tuberosity bone.

    External view of arthroscope in lateral portal (L) looking down on the two anchors from which four limbs of FiberTape can be seen coming up through the superolateral portal (SL).

    Use the scalpel to extend the lateral portal to accommodate an 8.25mm cannula.

    With the arthroscope in the posterior portal, place the switching stick into the lateral portal.

    Watch the switching stick into the subacromial space and ensure it’s opposite the tear so the instruments have good access to repair the tear.

    Operation – 6

    Take the Arthrex 8.25mm cannula mounted on the cannulated gold handle introducer and Insert cannula into the lateral portal

    Pass the cannula introducer over the switching stick

    Screw the cannula into the lateral portal

    Watch the metal tip of the introducer appear through the lateral portal into the subacromial space.

    With the cannula in the subacromial space, withdraw the metal introducer and switching stick.

    Looking from behind the shoulder with the arthroscope in the posterior (P) portal, 8.25mm cannula in lateral (L) and the four FiberTapes emanating from the superolateral (SL) portal.

    Use the shaver (S) in the lateral portal cannula.

    Further prepare the bony footprint of the greater tuberosity with the shaver.

    Take the tape retriever from the Arthrex shoulder instruments.

    Pass the tape retriever into the lateral cannula.

    Retrieve the FiberTapes using the lateral portal and load the Scorpion suture passerUse the tape retriever instrument to organise the tapes and choose the most anterior limb from the anteromedial anchor. There are two limbs of tape from each anchor and they will be positioned such that one will be relatively anterior compared to the other being posterior.

    Retrieve the most anterior tape.

    Pull the tape out through the lateral cannula.

    Take the Arthrex Scorpion suture passer instrument.

    Squeezing the handle of the Scorpion advances the needle through the trapdoor at the end of the instrument. This will push the tape through the tendon that is grasped in the jaws and the trapdoor captures the tape when the needle is retracted. This allows the tape to be pulled through the tendon as the instrument is withdrawn from the shoulder.

    Load the thin tapered end of the FiberTape that has been delivered out through the lateral portal into the Scorpion.The Scorpion is here shown with the jaws open.

    Close the jaws of the Scorpion and pass it into the lateral cannula.

    In the shoulder, open the jaws of the Scorpion and advance the instrument so that the edge of the tendon can be grasped between the jaws. A good bite of tendon is required so that the tape does not ‘cheesewire’ through the tissue when it’s pulled through. As this is the first and most anterior tape the position chosen to pass the tape should be at the front of the torn tendon.

    External view showing the Scorpion handle released which opens the jaws as previously seen inside the shoulder.

    Squeezing the handle of the Scorpion closes the jaws of the instrument around the grasped tendon and advances the needle pushing the end of the tape through the tissue and into the trapdoor.

    Pass the first and most anterior tape through the torn rotator cuff tendonArthroscopic image showing the needle (N) advancing through the trapdoor (TD) at the end of the instrument.

    Releasing the grip on the Scorpion handle opens the jaws of the instrument.

    With the jaws open and the end of the tape captured in the trapdoor, the instrument can be withdrawn from the shoulder pulling the tape through the tendon.

    Watch as the tape pulls through the tendon at the desired position as the Scorpion is withdrawn from the lateral cannula.

    Pull the length of FiberTape from the lateral cannula.

    Operation – 7

    Place the tape retriever into the lateral cannula.

    Retrieve the second tape from the lateral portal cannula using the retriever

    Identify the second tape, the posterior one from the anteromedial anchor and route it out through the lateral cannula.

    Having removed the second tape from the lateral cannula, place the retriever into the superolateral portal

    Take the first tape which has already been passed through the tendon out of the superolateral portalRetrieve the first tape which has already been passed through the tendon and remove it through the superolateral portal.

    Pull the first tape through the superolateral portal.

    Take the Scorpion again and load it with the second FiberTape

    Pass the Scorpion into the lateral cannula

    Pass the second FiberTape through the tendon using the ScorpionIn a repeat of the process used for the first tape passage, open the jaws of the Scorpion in order to take a bite of tendon.
    Grasp the torn tendon with the Scorpion with a good bite posterior to where the first tape was previously passed.

    Squeeze the handle of the Scorpion firmly to deploy the needle and pass the tape through the tendon tissue.

    With the tape captured in the Scorpion trapdoor remove it from the lateral cannula pulling the tape through the tendon

    With a couple of further squeezes on the Scorpion handle the needle deploys and releases the tape.

    Pass the third tape through the tendonRepeat the process of retrieving the next tape (anterior limb from posteromedial anchor) from lateral and the second tape to be already passed out of the superolateral portal. Then load the third tape onto the Scorpion and pass it through the torn tendon behind the position of the second one.
    Here the Scorpion is seen deploying the needle and passing the third tape through tendon tissue.

    Release the Scorpion handle and remove the third tape from the lateral cannula.

    Pass the fourth and final tape through the tendon.Repeat the process for the fourth and final tape and pass through the tendon in the most posterior position in relation to the tear. Here the Scorpion is grasping posterior tendon tissue.

    The Scorpion has deployed its needle passing the final tape through the tendon.

    Retrieve the final two FiberTapes through the superolateral portal. Here is the arthroscopic view from the posterior portal showing all the tapes passed through the tendon and now exiting the superolateral portal.

    Move the arthroscope to the lateral portal cannula.

    From the lateral portal inspect the rotator cuff tear (RCT) and all four FiberTapes passed through the tendon tissue: 1 & 2 from the anteromedial anchor and 3 & 4 from the posteromedial anchor.

    The schematic illustrates the achieved aim with the four tapes from the medial anchors passed through the tendon

    Return the arthroscope to the posterior portal by passing it over the switching stick and place the tape retriever instrument into the lateral cannula.

    Use the tape retriever to organise the tapes to identify their correct position in order.

    Take the anterior limb of tape from each anchor – that is the first and third to have been passed through the tendon.

    Take both these limbs of FiberTape in the retriever and remove them from the lateral cannula.

    This schematic illustrates taking the anterior pair of tapes.

    Operation – 8

    Remove the anterior limb of tape from each medial anchor from the lateral cannulaPull the tape retriever and the two tapes from the lateral cannula.

    For the lateral row of this double row rotator cuff repair technique I use the Arthrex 5.5mm BioSwivelock C anchors.These are slightly larger than the 4.75mm equivalents used for the medial row anchors as the bone in the lateral greater tuberosity tends to have thinner cortex and softer cancellous consistency and the larger anchor gets a better hold.

    Take the first lateral anchor, here shown on its blue inserter hand. The body of the anchor can be seen (B) with the eyelet (E) at the tip through which the wire loop of the orange suture threader passes.

    Pass the thin ends of the Fibertapes through the wire loop of the suture threader.

    Removing the orange handle of the suture threader pulls the tapes through the eyelet of the anchor.

    Load the anterolateral anchor with the anterior pair of tapes

    Place a simple artery clip (C) on the tapes to prevent the anchor falling off.

    Take the awl from the Arthrex arthroscopic shoulder instruments and pass down the lateral cannula alongside the tapes.

    Viewing arthroscopically from the posterior portal watch the tip of the awl exit the lateral cannula and position it on the lateral side of the greater tuberosity. Ideally for the anterolateral anchor it should be positioned in line with the anterior edge of the tear. Be careful not to stray too far anterior and into the bicipital groove which will interfere with the long head of biceps tendon and be a potential source of pain.

    The lateral cortex bone of the greater tuberosity is often thin enough that pushing downward pressure on the awl is sufficient to advance it into the bone. If that is not the case tapping with the mallet may be required.

    Watch the awl advance into the bone on the monitor. Note the laser markings FT (for the fully threaded BioCorkscrew anchor not being used here) and SL (for the SwiveLock anchor which is being used here).

    Advance the awl until the SL line is seated into the bone of the greater tuberosity, in advance of insertion of the Arthrex 5.5mm BioSwivelock C anchors.

    Withdraw the awl leaving the created hole and pulling on the clip to put the tapes on tension, slide the anchor eyelet along the taut tapes and down the lateral cannula.

    Advance the blue anchor inserter handle down the lateral cannula.

    Watch the monitor to see the anchor eyelet enter the subacromial space sliding along the tapes then find the pre-prepared anterolateral anchor hole and introduce the anchor eyelet into it.

    Now remove the clip from the tapes and sequentially pulling on each tape will reduce the rotator cuff tendon down onto the bony footprint of the greater tuberosity. Keep pressure on the flat square paddle on the anchor introducer handle to keep the anchor eyelet in the hole.

    Watch the tapes pulling the tendon down onto the bone and advance the anchor into the hole.

    Adjust the position of the anchor introducer handle to optimise the tension on the tapes and position of the anchor into the hole.

    Advance the eyelet into the hole until the body of the anchor sits at the mouth of the hole.

    Maintaining tension on the FiberTapes, screw in the anchor by holding the flat square paddle (S) and turning the pear-shaped handle (P) clockwise. “Hold the square and turn the pear”.

    Watch the arthroscopic monitor as the body of the anchor screws into the bone taking with it the FiberTapes for interference fixation in the greater tuberosity bone.

    Screw in the anchor until the body disappears into the bone and flare at the distal end of the blue inserter handle starts to enter the hole.

    Unwind the core sutures from the pear-shaped handle, remove the blue introducer handle and then pull one limb of the core suture to remove it fully from the lateral cannula.

    Cut the tapes from the anterolateral anchorTake the Arthrex tape cutter

    Pass the thin ends of the FiberTapes through the top of the end of the cutter.

    Operation – 9

    Slide the cutter down the tapes into the lateral cannula.

    Advance the cutter up against the bone.

    Squeeze the handle of the cutter

    Ensure both tapes are divided by the cutter.

    Check the position of the tapes fixed down to the anterolateral anchor.

    Use the tape retriever in the lateral cannula.

    Retrieve the second pair of tapes from the lateral cannula.

    Load the second 5.5mm BioswiveLock anchor onto the tapes.

    Load the posterior pair of tapes into the posterolateral anchor.

    Use the awl to make the hole for the posterolateral anchor.

    Position the awl in line with the posterior aspect of the tear for the posterolateral anchor.

    Push (or tap with the mallet) the awl into the bone to create the hole for the posterolateral anchor.

    Remove the awl

    Complete the rotator cuff repair by inserting the posterolateral anchorSlide the anchor down the tapes into the lateral cannula.

    Advance the anchor eyelet into the posterolateral hole.

    Push the blue anchor introducer handle down the cannula. and tension the tapes individually to reduce the tendon to the bone.

    Advance so the anchor body sits on the bone.

    Screw the anchor into the bone

    Cut the tapes with the Arthrex arthroscopic tape cutter

    Check the tapes fixed down to the posterolateral anchor.

    Finish the subacromial decompression by performing the bony acromioplastyPass the arthroscopic shaver down the lateral cannula.

    Inspect the undersurface of the acromion and the subacromial spur (SAS).

    Starting from the lateral aspect of the acromion use the high speed shaver to resect bone from the anterior acromion. Used in fast forward mode this Smith & Nephew bone cutter attachment is efficient in resecting bone.

    External view of the shaver in the lateral portal and the resection of the acromion seen on the monitor.

    Operation – 10

    When the anterior acromion has been resected, move the arthroscope to the lateral cannula. Here the light lead has been rotated to the top to look down.

    Looking down on the rotator cuff repair the blue FiberTapes are seen crossing over the edge of the tendon.

    Think back to how the rotator cuff tear looked from the lateral view prior to the repair: greater tuberosity footprint (FP); articular cartilage of the humeral head (HH) and the rotator cuff tear (RCT)

    Now the same view of the repair shows the tendon edge (TE) with the blue FiberTapes crossed over and fixed down to the anterolateral (AL) and posterolateral (PL) anchors. A double row four anchor repair using FiberTape sutures.

    Place the shaver into the posterior portal to complete the acromioplasty.

    From the posterior portal sweep the shaver under the acromion from medial to lateral resecting the residual bone spur.
    The completed acromioplasty viewed from lateral portal showing the smooth undersurface of the acromion.

    Remove the cannula by unscrewing it from the lateral portal.

    Stitch the arthroscopic portals.Close the three portal with simple Nylon stitches.

    Three arthroscopic portals closed with simple Nylon stitches.

    Apply dressings and sling
    Cover portals with simple adhesive absorbant dressings.

    Take the arm out of the Spider arm holder, remove the drapes and apply an absorbant pad over the dressings.

    Stick the absorbant pad down to the shoulder with adhesive Mefix tape.

    Place the arm in a broad polysling to complete the procedure.

    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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