Perioperative Care of the Patient
Arthroscopic rotator cuff repair is often a very painful procedure if
multimodality pain management is not utilized in the perioperative and
postoperative period. We believe that the intraoperative use of an
interscalene block provides optimal patient management during this procedure.
The interscalene block facilitates intraoperative blood-pressure control by
the anesthesia team since it blunts the sympathetic response to pain during
surgery that would otherwise result in periods of intraoperative hypertension.
Hypertension can complicate arthroscopic visualization by increasing bleeding
and making hemostasis difficult to achieve. We prefer controlled hypotension
for our patients during rotator cuff repair, recognizing that maintenance of
good cerebral blood flow is crucial to protect patients from catastrophic
cerebral injury. There is a theoretical risk of air embolism in the
beach-chair position; however, we have never observed this complication in our
patients, and we are not aware of any reports in the literature of air
embolism related to the beach-chair position during arthroscopic surgery.
The patient is placed in the beach-chair position for the procedure with
the arm forward flexed with approximately 1.5 to 3 kg of skin traction applied
(Fig. 1). Before the extremity
is placed in traction, and before it is wrapped, it is important to adequately
pad the hand and forearm with gauze or foam in order to avoid injuries to the
skin from traction and to avoid excessive nerve compression about the forearm
and wrist.
Arthroscopic Double-Row Suture Anchor Repair
Next, a modified posterior portal ("A" in
Figs. 2-A and 2-B) is used for
entry into the glenohumeral joint. We typically use a spinal needle in order
to localize the glenohumeral joint. It is important, when a rotator cuff
repair is being done, to move the traditional location of the posterior portal
slightly superior to the location that is used in procedures focusing on
intra-articular pathology. As most of the work for rotator cuff repairs is
performed in the subacromial space, our preferred location for the posterior
portal is approximately 10 mm inferior to the scapular spine, in line with the
sagittal plane of the glenohumeral joint. A number-11 blade is used to make a
small incision in the skin, and a trocar is introduced into the glenohumeral
joint. Systematic diagnostic arthroscopy is performed with the camera before
the glenohumeral joint is distended with saline solution. In particular, the
size of the rotator cuff tear is assessed along with other commonly observed
lesions involving the subscapularis and biceps tendons, the glenohumeral
articular surfaces, and the labrum.
At the conclusion of the diagnostic arthroscopy, the camera is removed from
the joint and the trocar and the camera sheath are repositioned into the
subacromial space through the posterior portal. The tip of the blunt trocar
should palpate the coracoacromial ligament and rest lateral to it. The camera
is introduced, and the subdeltoid space is filled with saline solution. A
20-gauge needle is used to establish a lateral portal ("C" in
Figs. 2-A and 2-B). This portal
should be approximately 1.5 to 2 cm lateral to the lateral edge of the
acromion. A common error is to make the portal too superior, which results in
difficulty with visualization of the rotator cuff as a result of the overhang
of the acromion. The lateral portal is used to introduce the arthroscopic
shaver and radiofrequency device for the subacromial decompression and
acromioplasty (Fig. 3). First,
the pathologically involved bursa is removed and is carefully coagulated, and
the undersurface of the acromion is cleared of adhesions to facilitate
identification of its anterior and lateral borders. Next, a burr is used to
perform an acromioplasty. In our opinion, the amount of bone resected during
the acromioplasty is dictated by the access needed to perform the rotator cuff
repair and to achieve the visualization necessary to evaluate the rotator cuff
after reconstruction.
Once the undersurface of the acromion has been cleared of adhesions and the
bursal tissue lateral to the coracoacromial ligament has been resected, the
camera is moved to the lateral ("C") portal. We believe that this
portal provides the optimal view for evaluating the configuration of the
rotator cuff tear, performing the releases necessary for tension-free rotator
cuff reconstruction, and passing and tying the sutures. Visualization through
the lateral portal also affords the opportunity to reassess the adequacy of
the acromioplasty since the three-dimensional shape of the acromion can best
be appreciated from two different arthroscopic portals that are orthogonally
placed.
Once the camera is in the lateral portal, the posterior portal can be used
for instrumentation and completion of the rotator cuff release. If necessary,
a spinal needle is used to create either an accessory anterolateral portal
("D" in Figs. 2-A and
2-B) or an accessory posterolateral portal ("B" in
Figs. 2-A and 2-B) for
instrumentation, according to the location and configuration of the tear. The
spinal needle should be used as a guide for determining the most efficacious
position for the accessory portals on the basis of the point that enables the
most liberal access to the subdeltoid space. We often extend the subdeltoid
débridement to the base of the coracoid anteromedially, to the spine of
the scapula posteromedially, and circumferentially around the humerus
anteriorly, laterally, and posteriorly, an area commonly referred to as the
lateral gutter. The goal is to achieve a global perspective of the
rotator cuff from the lateral ("C") portal so that the
subscapularis, supraspinatus, infraspinatus, teres minor, and biceps can all
be visualized easily.
The techniques employed to carry out releases required for larger rotator
cuff tears are based on the tear configuration, the degree of retraction, and
the quality of the torn tendons. In general, the principles are the same as
those used in the mobilization of retracted tissues during open surgical
procedures. Common techniques include resection of the rotator interval all of
the way to the base of the coracoid, release of adhesions between the
undersurface of the rotator cuff and the glenoid labrum and capsule, and the
so-called posterior interval slide as described by Lo and
Burkhart11. The key
to a tension-free repair of the rotator cuff, particularly one with a larger
tear, is to perform an adequate release of the rotator cuff tendons and
reapproximate the rotator cuff in line with the direction of retraction of the
fibers of each muscle. This is the purpose of understanding the configuration
of the rotator cuff tear—i.e., in order to understand the direction of
retraction of the fibers of each rotator cuff tendon, so that the best
reduction of the tear can be achieved. The key to performing an adequate
release of a large, retracted anterosuperior rotator cuff tear is to identify
the coracohumeral ligament and widely resect the rotator interval. If
necessary, the coracohumeral ligament can be released from its attachment near
the base of the coracoid; it is very important, however, to never separate the
distal part of the supraspinatus tendon from its attachment to the
coracohumeral ligament and the subscapularis as this greatly compromises the
strength of the distal part of the tendon. Traction sutures may further aid in
exposing adhesions to the rotator cuff during the release of the tendon and
muscle tissues.
Once an adequate release of the rotator cuff has been performed and the
débridement of the subdeltoid space has been completed, the greater
tuberosity footprint is cleared of the rotator cuff remnant and adhesions with
use of either electrocautery or an arthroscopic shaver. We no longer
decorticate the greater tuberosity as we believe that preserving the strength
of the cortical bone in the tuberosity provides improved fixation strength for
the suture anchors and, therefore, superior durability of the repair.
Next, the suture anchors are placed along the medial border of the anatomic
footprint on the greater tuberosity. Typically, anchors can be placed from the
anterolateral ("D") portal, or, as is sometimes necessary because
of the size of the tear and its configuration, a posterolateral
("B") portal is established for this purpose. In most double-row
suture anchor reconstructions, two anchors are placed medially at the junction
of the articulating surface of the humerus and the greater tuberosity
footprint and the sutures are passed through the tendon prior to the placement
of another one or two anchors on the lateral edge of the footprint or the
lateral cortex of the humerus (Figs. 4-A,
4-B, and 4-C). The angle of insertion of the suture anchors should
be at approximately 45°, or the "deadman's angle" as described
by Burkhart12, in
order to maximize the pull-out strength of the anchors and minimize the
tension on the sutures used to repair the rotator cuff.
Once an anchor has been inserted, the posterolateral and anterolateral
("B" and "D") portals are usually used to retrieve the
sutures with a hook device, depending on the pattern and size of the tear. It
is important to always shuttle the sutures out of a different portal than the
one used to retrieve the sutures with the hook prior to passing the sutures
through the rotator cuff. When all of the sutures from each anchor are passed
through the rotator cuff, they should be clamped together outside of the skin
in order to optimize suture management and avoid entanglement. All of the
sutures coming from the same anchor are grasped and are placed in a small
silicone catheter; the catheter is pushed into the subacromial space with
tension on the sutures so that a reduction of the rotator cuff to the
tuberosity is achieved. Once all of the sutures from the medial anchors are
passed through the rotator cuff, the lateral-row anchors can be placed with
use of either or both the posterolateral and anterolateral portals, as
determined by the pattern and size of the rotator cuff tear
(Fig. 5).
In order to maximize visualization of the lateral cortex of the humerus
during the procedure and to prevent encroachment of the bursa into the visual
field, we utilize silicone balloons, from urological catheters, placed through
the inferolateral portals (Fig.
6). The lateral-row sutures are passed through the rotator cuff
with use of either the posterolateral or the anterolateral ("B" or
"D") portal, as was done with the medial-row sutures, except that
the lasso-loop
configuration13 is
employed (Fig. 7). In order to
perform the lasso loop, the retrieval hook is used on the lateral edge of the
rotator cuff tendon to retrieve a suture from the anchor. When the suture is
pulled through the superior surface of the rotator cuff, it makes a loop. The
suture is released from the retrieval hook at this point, and the curved tip
of this device is used to enter the loop formed by the retrieved suture having
been pulled through the superior aspect of the rotator cuff. The hook is then
used to retrieve the free end of the same suture that is forming the loop and
to pull the end of the suture through the loop and outside of the body. The
lasso-loop technique, we believe, allows superior fixation of the tissues by
approximating a Mason-Allen suture configuration through the rotator
cuff1.
Once all of the sutures are passed, the lateral-row sutures are first tied
in order to effect the reduction of the rotator cuff. The medial-row sutures
are then tied to appose the rotator cuff tissue to the medial footprint
adjacent to the articular surface of the humeral head
(Fig. 8). The suture ends are
cut, and the reconstruction is complete.
CRITICAL CONCEPTSINDICATIONS:We believe that the majority of large or massive rotator cuff tears are
amenable to double-row suture anchor repair. While it is usually technically
possible to fix a small rotator cuff tear with a double-row suture anchor
technique, we do not think that it is necessary in the majority of cases. In
general, we prefer to repair most full-thickness rotator cuff tears that are
smaller than 10 mm in the sagittal plane with a single suture anchor placed on
the lateral edge of the supraspinatus footprint with use of the lasso-loop
suture configuration. Otherwise, we repair all rotator cuff tears using the
double-row suture anchor repair.CONTRAINDICATIONS:Partial-thickness rotator cuff tears. We do not recommend double-row
rotator cuff repair for partial-thickness rotator cuff tears. Most of these
tears are quite small even if they are completed by the surgeon. It has been
our experience that use of a single double-loaded suture anchor usually
results in a satisfactory repair.Partial repairs of massive rotator cuff tears. Certain massive rotator cuff
tears can be only partially repaired because of the degree of retraction and
the poor quality of the involved tissue. These tears usually include an
irreparable supraspinatus tear with a Patte Stage-3 infraspinatus
tear14. In these
relatively rare cases, the goal of the partial rotator cuff repair is to
reconstruct the posterior part of the rotator cuff and restore the force
couple between the subscapularis anteriorly and the infraspinatus and teres
minor
posteriorly15.
Tears with extensive retraction often do not lend themselves to double-row
suture anchor repair since it is not possible to mobilize the superior part of
the rotator cuff adequately to accomplish a tension-free repair. We recommend
single-row repairs for these cases if the ability to mobilize the
infraspinatus laterally is limited by the loss of plasticity in the muscle and
the degree of retraction does not enable a footprint reconstruction that is
tension-free.PITFALLS:Inadequate bursectomy and rotator cuff release. It is imperative that the
surgeon take the time to do an extensive débridement of the subacromial
space and perform an adequate release of the rotator cuff. If visualization is
hampered by an inadequate débridement, the quality of the rotator cuff
repair will undoubtedly be diminished. Likewise, if the rotator cuff is not
adequately released, then the rotator cuff, even if it is repaired, may fail
postoperatively as a result of tension overload at the medial
anchors16.Portal placement. One should use a spinal needle to determine the optimum
location for portal placement prior to cutting the skin and establishing the
definitive portal. A poorly placed portal can make rotator cuff repair
technically very difficult. The surgeon should consider the tear configuration
and the direction of the reduction when making each portal.The lasso-loop technique. When performing the lasso-loop technique, the
surgeon must remain aware of the danger of dethreading the anchor when pulling
the suture through the loop. In order to avoid this complication,
visualization of the anchor should be maintained when the suture is pulled out
through the loop.Suture management. The sutures from each anchor should be kept separate by
clamping all of the sutures from the same anchor together outside of the
skin.AUTHOR UPDATE:There have been no changes in the technique since the publication of the
original article.
CRITICAL CONCEPTS
INDICATIONS:
We believe that the majority of large or massive rotator cuff tears are
amenable to double-row suture anchor repair. While it is usually technically
possible to fix a small rotator cuff tear with a double-row suture anchor
technique, we do not think that it is necessary in the majority of cases. In
general, we prefer to repair most full-thickness rotator cuff tears that are
smaller than 10 mm in the sagittal plane with a single suture anchor placed on
the lateral edge of the supraspinatus footprint with use of the lasso-loop
suture configuration. Otherwise, we repair all rotator cuff tears using the
double-row suture anchor repair.
CONTRAINDICATIONS:
Partial-thickness rotator cuff tears. We do not recommend double-row
rotator cuff repair for partial-thickness rotator cuff tears. Most of these
tears are quite small even if they are completed by the surgeon. It has been
our experience that use of a single double-loaded suture anchor usually
results in a satisfactory repair.Partial repairs of massive rotator cuff tears. Certain massive rotator cuff
tears can be only partially repaired because of the degree of retraction and
the poor quality of the involved tissue. These tears usually include an
irreparable supraspinatus tear with a Patte Stage-3 infraspinatus
tear14. In these
relatively rare cases, the goal of the partial rotator cuff repair is to
reconstruct the posterior part of the rotator cuff and restore the force
couple between the subscapularis anteriorly and the infraspinatus and teres
minor
posteriorly15.
Tears with extensive retraction often do not lend themselves to double-row
suture anchor repair since it is not possible to mobilize the superior part of
the rotator cuff adequately to accomplish a tension-free repair. We recommend
single-row repairs for these cases if the ability to mobilize the
infraspinatus laterally is limited by the loss of plasticity in the muscle and
the degree of retraction does not enable a footprint reconstruction that is
tension-free.
Partial-thickness rotator cuff tears. We do not recommend double-row
rotator cuff repair for partial-thickness rotator cuff tears. Most of these
tears are quite small even if they are completed by the surgeon. It has been
our experience that use of a single double-loaded suture anchor usually
results in a satisfactory repair.
Partial repairs of massive rotator cuff tears. Certain massive rotator cuff
tears can be only partially repaired because of the degree of retraction and
the poor quality of the involved tissue. These tears usually include an
irreparable supraspinatus tear with a Patte Stage-3 infraspinatus
tear14. In these
relatively rare cases, the goal of the partial rotator cuff repair is to
reconstruct the posterior part of the rotator cuff and restore the force
couple between the subscapularis anteriorly and the infraspinatus and teres
minor
posteriorly15.
Tears with extensive retraction often do not lend themselves to double-row
suture anchor repair since it is not possible to mobilize the superior part of
the rotator cuff adequately to accomplish a tension-free repair. We recommend
single-row repairs for these cases if the ability to mobilize the
infraspinatus laterally is limited by the loss of plasticity in the muscle and
the degree of retraction does not enable a footprint reconstruction that is
tension-free.
PITFALLS:
Inadequate bursectomy and rotator cuff release. It is imperative that the
surgeon take the time to do an extensive débridement of the subacromial
space and perform an adequate release of the rotator cuff. If visualization is
hampered by an inadequate débridement, the quality of the rotator cuff
repair will undoubtedly be diminished. Likewise, if the rotator cuff is not
adequately released, then the rotator cuff, even if it is repaired, may fail
postoperatively as a result of tension overload at the medial
anchors16.Portal placement. One should use a spinal needle to determine the optimum
location for portal placement prior to cutting the skin and establishing the
definitive portal. A poorly placed portal can make rotator cuff repair
technically very difficult. The surgeon should consider the tear configuration
and the direction of the reduction when making each portal.The lasso-loop technique. When performing the lasso-loop technique, the
surgeon must remain aware of the danger of dethreading the anchor when pulling
the suture through the loop. In order to avoid this complication,
visualization of the anchor should be maintained when the suture is pulled out
through the loop.Suture management. The sutures from each anchor should be kept separate by
clamping all of the sutures from the same anchor together outside of the
skin.
Inadequate bursectomy and rotator cuff release. It is imperative that the
surgeon take the time to do an extensive débridement of the subacromial
space and perform an adequate release of the rotator cuff. If visualization is
hampered by an inadequate débridement, the quality of the rotator cuff
repair will undoubtedly be diminished. Likewise, if the rotator cuff is not
adequately released, then the rotator cuff, even if it is repaired, may fail
postoperatively as a result of tension overload at the medial
anchors16.
Portal placement. One should use a spinal needle to determine the optimum
location for portal placement prior to cutting the skin and establishing the
definitive portal. A poorly placed portal can make rotator cuff repair
technically very difficult. The surgeon should consider the tear configuration
and the direction of the reduction when making each portal.
The lasso-loop technique. When performing the lasso-loop technique, the
surgeon must remain aware of the danger of dethreading the anchor when pulling
the suture through the loop. In order to avoid this complication,
visualization of the anchor should be maintained when the suture is pulled out
through the loop.
Suture management. The sutures from each anchor should be kept separate by
clamping all of the sutures from the same anchor together outside of the
skin.
AUTHOR UPDATE:
There have been no changes in the technique since the publication of the
original article.