Setup
Routine use of preoperative intravenous antibiotics is recommended. The surgical procedure is performed with the patient under general endotracheal anesthesia supplemented with preoperative interscalene regional anesthesia for postoperative pain control. We prefer the beach-chair position for ease of setup and freedom of arm and shoulder movement. Lower-extremity compression stockings and sequential compression devices are utilized for perioperative mechanical prophylaxis against deep vein thrombosis. An articulating positioner (McConnell, Greenville, Texas) assists in holding the operatively treated extremity during the procedure and allows the application of distal traction to facilitate subacromial arthroscopy.
Portal Placement
After draping, a subacromial injection of a solution of 20 mL of 0.25% Marcaine (bupivacaine) mixed with 1:100,000 epinephrine is performed to aid in hemostasis. We prefer low pump pressures (=40 mm Hg) to slow soft-tissue swelling. The portal sites are then marked. The posterior portal is placed approximately 3 cm distal and slightly medial to the posterolateral edge of the acromion. The anterior portal is marked immediately lateral to the coracoid process. Two lateral portals, one anterior and one posterior, are located at equidistant intervals along the lateral edge of the acromion, approximately 3 cm distally. All portals that will be used for rotator cuff repair should be placed distal enough to allow continued access to the subacromial space despite progressive shoulder swelling. Percutaneous portals along the lateral edge of the acromion are used for the placement of medial-row suture anchors. The portal of Neviaser, located immediately posterior to the posterior edge of the acromioclavicular joint, may be used for antegrade suture passage.
Intra-Articular Assessment
The posterior portal is created, and a 4-mm, 30° arthroscope is introduced. The anterior portal is then localized through the rotator interval, and a small cannula is introduced. Systematic diagnostic arthroscopy, including careful examination of the glenoid and humeral head articular surfaces, the long head of the biceps brachii tendon, and the entire rotator cuff insertion, is performed. The surgeon should proceed with caution if extensive chondrosis is encountered, as a patient with this condition may develop stiffness or have persistent pain postoperatively. The biceps tendon is carefully inspected for evidence of degeneration, tearing, or instability (Fig. 1). We prefer to address the biceps tendon, especially in the setting of revision rotator cuff repair, if there is any evidence of instability or degeneration/fraying of >25% of the width of the tendon. The selection of biceps tenotomy or tenodesis should be based on the preference of the surgeon and is generally based on the age, body habitus, and activity level of the patient. The upper portion of the subscapularis tendon insertion should also be inspected to identify associated tears.
The torn posterior part of the rotator cuff is then inspected from the intra-articular perspective to determine the extent of the tear, degree of retraction, quality of the tissue, and presence of delamination. Prominent suture material or suture anchors are sought and are removed if present in the glenohumeral joint space. Adhesions and scar formation in the glenohumeral joint are often encountered during a revision rotator cuff repair and are addressed by releasing adhesions between the glenoid labrum and the undersurface of the rotator cuff with use of an electrocautery wand or a shaver. This is particularly important in the superior and posterior quadrants of the glenoid, where tear retraction and subsequent adhesions are greatest. Care should be taken to avoid the use of the electrocautery wand or the shaver >15 mm medial to the glenoid rim to prevent injury to the suprascapular nerve within the spinoglenoid notch.
Subacromial Assessment
Following intra-articular diagnostic arthroscopy, the arthroscope is introduced into the subacromial space from the posterior portal. The bursa is swept in a systematic manner from medial to lateral along the entire length of the acromion, beginning posteriorly, to clear the subacromial space. The anterolateral portal is then established, and a comprehensive bursectomy is performed with use of the arthroscopic shaver and electrocautery device. Careful attention is given to the bursectomy posteriorly and laterally, with removal of the veil of tissue that often obscures the rotator cuff tendon below. Often, it is difficult to differentiate thickened or scarred bursal tissue from the underlying rotator cuff tendons. We have found it useful to complete the bursectomy while viewing from the anterolateral subacromial portal, where the deeper rotator cuff tendons are easier to visualize. In addition, it is helpful to remember that subacromial tissue in continuity with the deep deltoid fascia usually represents bursal tissue and can be safely debrided, thereby exposing the deeper torn rotator cuff tendons. A comprehensive bursectomy allows full assessment of cuff tear morphology, helps to mobilize the cuff tendons, and facilitates later suture passage and lateral-row suture-anchor placement. Residual suture material is often seen attached to previously placed anchors or bone tunnels in the greater tuberosity, and it should be removed at this point.
The acromion is then evaluated. Its anterior and lateral borders are defined with use of the radiofrequency device. The coracoacromial ligament (or remnant) is released from the inferior surface of the anterior aspect of the acromion. Care is taken to preserve the deep deltoid fascia. A formal acromioplasty is performed, judiciously, only if a true acromial spur is present. Sufficient bone is removed to create a flat surface with enough space to perform the rotator cuff repair.
Rotator Cuff Tendon Mobilization
The posterolateral portal is then established, and large-bore threaded cannulas are placed in each lateral portal (Fig. 2). In addition, a large-bore cannula is placed anteriorly under the acromial edge, thus providing three subacromial working portals. The arthroscope is moved to one of the lateral portals to visualize the rotator cuff tear. Debridement of the rotator cuff tear is performed to define the tear edge, with care taken to preserve as much tissue substance as possible. The rotator cuff tear is then carefully inspected to allow recognition of the tear pattern (Fig. 3). A tissue grasper can be inserted through a lateral portal to determine the optimal method of reducing the tear to its footprint and to assess the degree of retraction and mobility of the tissue. Care is taken to identify any deep tendon delamination, which is common at the more posterior aspect of the tear (Fig. 4). Differential retraction of the layers of a delaminated tendon can be seen and must be recognized for complete tendon mobilization and repair. Reduction of the tear to the greater tuberosity must be possible without excessive tension to ensure successful healing. All of these factors together determine the technique used for repair (single versus double row) as well as the location of anchor placement and suture passage.
In the case of revision rotator cuff repair, the chronicity of the tear as well as scar and adhesion formation from previous procedures often compromise tear mobility. Therefore, aggressive releases may be necessary. With viewing from the posterolateral portal, intra-articular releases are completed. The electrocautery device is used to perform a capsulotomy at the glenoid articular margin (Fig. 5). The rotator cuff tissue is then released from the glenoid rim and scapular neck. Next, attention is turned to subacromial soft-tissue releases. Again, these steps are facilitated by viewing from a lateral subacromial portal. Frequently, in revision surgery, adhesions of the rotator cuff to the undersurface of the acromion are encountered and are released with use of the electrocautery device (Fig. 6). The undersurface of the scapular spine is exposed to ensure mobility of the torn tendon in this area (Fig. 7). Traction sutures are often placed to maintain tension on the rotator cuff and facilitate the release of adhesions. During this portion of the procedure, the mobility of the tendon is periodically assessed to determine if it can be reduced to the tuberosity. If, despite comprehensive releases, the tendon is not yet adequately mobilized, anterior or posterior interval slides can be performed. We frequently perform an anterior interval release separating the anterior edge of the supraspinatus from the interval capsule using scissors and an electrocautery device. The release is taken medially to the coracoid base, ensuring a full release of the coracohumeral ligament (Figs. 8-A and 8-B). We prefer to avoid a posterior interval slide unless the infraspinatus cannot be mobilized because of its attachment to a severely retracted supraspinatus tendon. Often, a posterior interval slide is performed when the supraspinatus tendon is deemed irreparable.
Rotator Cuff Repair
At this point, the greater tuberosity surface is prepared. Residual soft-tissue and suture material are removed with use of the arthroscopic shaver. Previously placed anchors are removed only when they are prominent or when crowding of the greater tuberosity is seen. The burr is then utilized to abrade the cortical bone of the greater tuberosity to facilitate bleeding of the osseous surface. We consider this step to be very important to facilitate tendon healing, especially in a revision rotator cuff repair.
A final assessment of tendon mobility is performed, and the method of reduction of the tear to the tuberosity is confirmed. If the torn tendon edge can be mobilized to cover at least 50% of the width of the greater tuberosity, we prefer to perform a double-row repair. In the case of limited tendon excursion despite releases, or of extensive tissue loss, it may be impossible to reduce the tear to its entire native footprint on the tuberosity without excessive tension. In these situations, a single-row repair is performed. Currently, we prefer a suture-bridge repair construct as our primary type of double-row fixation.
A margin convergence type of repair is occasionally warranted for certain tear patterns prior to tendon-to-bone fixation. We perform a margin convergence repair when there is a long medial split in the torn tendon or when the tear pattern demonstrates a tear apex that is too medial for lateralization to the tuberosity in the presence of intact anterior and posterior cuff tissue. In this situation, the tear edges are debrided. Free nonabsorbable high-tensile-strength number-2 sutures are passed through the posterior tear edge medially with a suture-passing device. The anterior limb of the medial split is then pierced with a suture-retrieving device, and the opposite limbs of each suture are sequentially retrieved. Knots are then tied, bringing the anterior and posterior tear edges together and effectively lateralizing the tear edge for tendon-to-bone fixation.
A spinal needle is used to localize a percutaneous portal along the anterolateral edge of the acromion for anchor insertion at an angle of approximately 45° relative to the horizontal. For single-row repair, the anchors are placed midway from the humeral head articular surface to the lateral edge of the tuberosity, beginning anteriorly. A 3-mm skin incision is created, and a 5.5-mm threaded metal anchor loaded with two nonabsorbable high-tensile-strength sutures is inserted. The anchor is inserted just below the level of the cortex, and the eyelet is oriented in line with the long axis of the tendon. Additional anchors are then inserted in a similar manner, either through the same percutaneous portal with shoulder rotation to access the remainder of the tuberosity or through additional percutaneous portals placed more posteriorly along the acromion. If adequate mobility of the rotator cuff has been achieved, a double-row repair is performed. Insertion of the medial-row anchors proceeds in a manner similar to that used for a single-row repair (Figs. 9-A and 9-B). However, the medial row is placed immediately adjacent to the humeral head articular surface, and the anchor eyelets are oriented perpendicular to the long axis of the tendon to minimize suture abrasion on the eyelet after suture passage in a horizontal mattress fashion.
Single-Row Repair
The arthroscope is then inserted through the posterolateral portal for suture passage. One limb of each suture from the anterior anchor is retrieved from the anterolateral portal. The suture limb is passed in through the anterior portion of the torn tendon with a retrograde suture-passing device in a simple fashion. Alternatively, a cannulated antegrade suture-passing device can be used from the anterior edge of the acromion or the portal of Neviaser. The passed suture limb is retrieved from the anterior portal. This procedure is repeated with one limb from both sutures of each anchor. Once all sutures have been passed, knot tying is performed through the anterolateral portal with viewing from the posterior portal. The suture limbs are then cut for single-row repair.
Double-Row Repair
For a double-row suture-bridge repair, both limbs of the medial-row anchor sutures are passed through the rotator cuff tendon, creating horizontal mattress stitches (Fig. 10). Care is taken to incorporate all layers of the torn tendons when delamination is encountered, especially at the posterior margin of the tear. Visualization during suture passage is facilitated by viewing from a lateral portal. All layers of the tendon can be captured easily with the use of a cannulated suture-passing device loaded with a wire or suture loop (Fig. 11). Differential retraction of the tendon layers can be controlled with traction sutures or a tissue grasper while the sutures are passed through the tendon. The medial-row sutures are tied initially, before lateral-row anchor insertion (Fig. 12). Maintaining tension on the traction sutures while tying the medial row will aid in the reduction of the tendon to the bone. A systematic approach is necessary for determining the post for knot tying. For example, if the anterior limb is chosen for the first set of sutures, the anterior limb should be chosen for all others. Choosing the anterior limb for sutures from the anterior anchor and the posterior limb for sutures from the posterior anchor leads to excessive spread of the knots over the repair, which is problematic when the limbs are brought over the top of the repair for the lateral row. The suture limbs are preserved for knotless fixation laterally.
One suture limb from each tied medial-row suture is retrieved through the posterolateral portal, and the other is retrieved through the anterolateral portal (Fig. 13). The number of limbs to be incorporated in each lateral anchor depends in part on the number of medial anchors utilized. The extremity is brought into internal rotation and abduction to reveal the posterolateral aspect of the greater tuberosity. The sutures from the posterolateral portal are loaded through a 4.75-mm threaded knotless suture anchor (Fig. 14). Just as the medial-row anchors are spaced equally along the medial aspect of the rotator cuff tear footprint, the lateral-row anchors should be spaced equally along the rotator cuff tear footprint on the lateral aspect of the greater tuberosity. The posterolateral anchor is then inserted approximately 5 mm distal to the lateral edge of the tuberosity, while appropriate traction on the suture limbs is maintained to reduce the tendon on its footprint. The arm is then externally rotated, and the anterolateral anchor is inserted in a similar manner. A safety knot is tied with the suture limbs to prevent pullout, and the suture limbs are then cut and discarded. The extremity is brought back into adduction. The arthroscope is introduced into the anterolateral portal, and the repair is inspected while the extremity is brought through a gentle range of motion (Fig. 15).
We advocate a delayed physical therapy regimen after revision rotator cuff repair to allow adequate time for tendon healing. Shoulders are immobilized for a six-week period with a sling and pillow. The sling is removed several times per day to allow active movement of the elbow, wrist, and hand and may also be removed periodically for self-care and comfort so long as the shoulder remains relaxed. At six weeks, a passive range of motion of the shoulder is allowed with prescribed physical therapy or the use of a continuous passive motion machine. Emphasized motions include passive flexion, scapular plane abduction, and external rotation as tolerated, while internal rotation is avoided. Use of the sling can be discontinued at this point, but it is typically worn outside the home. At three months, active-assisted and active range-of-motion exercises are initiated. Strengthening exercises for the rotator cuff, deltoid, and scapular stabilizers are initiated at four months postoperatively. The time until the patient returns to work is individualized on the basis of his or her specific work demands. Return to employment requiring manual labor is typically delayed for four to six months, depending on individual progression with rehabilitation.
INDICATIONS:
The indications for attempted revision arthroscopic rotator cuff repair are relative. Unfortunately, the final determination of whether or not a recurrent tendon defect is repairable is made at the time of surgery. We consider revision rotator cuff repair for patients with a physiologic age under sixty-five years who have persistent pain and limited shoulder function and documented failure of healing following a previous repair. Patients should have an intact or repairable subscapularis and good deltoid function. They should have at least 90° of active elevation and minimal to no external rotation lag signs. Ideal candidates have no more than Goutallier14 stage-2 fatty infiltration of the involved rotator cuff tendons, but surgery can be considered for more advanced stages if the tendon is mobile enough for repair at the time of surgery.
CONTRAINDICATIONS:
Absolute:
- Active infection
- Advanced radiographic signs of arthritis
- Fixed proximal humeral migration with contact of the humeral head against the acromion
- Proximal humeral escape
- Pseudoparalysis
- Deltoid insufficiency or axillary nerve palsy
Relative:
- Advanced muscle atrophy (Goutallier stage 3 or 4) with tendon retraction to the glenoid rim
- A recurrent posterior rotator cuff tear with irreparable subscapularis injury
- Age of more than sixty-five years
- Tobacco use
PITFALLS:
- An understanding of the proper indications is necessary to identify patients who will likely benefit from revision rotator cuff repair and to help to identify tears that are potentially repairable. Revision rotator cuff repair is not indicated for many patients, as noted above.
- Failure to recognize and treat other potential shoulder pain generators, such as symptomatic acromioclavicular joint arthritis, subscapularis tears, biceps tendon disease, and suprascapular nerve entrapment, can compromise success.
- A comprehensive debridement of subacromial bursal and scar tissue is needed for proper visualization and assessment of the rotator cuff tendon tear pattern and associated tendon loss.
- Adequate mobilization of retracted tears requires complete articular side and bursal side release of adhesions and frequently release of the interval capsule.
- The preliminary aspects of the surgery (diagnostic arthroscopy, subacromial debridement, tendon mobilization, and removal of prior sutures) must be performed quickly to avoid prohibitive tissue swelling. Lower pump pressures can slow the progression of soft-tissue swelling.
- After tendon releases and debridement, the mobility of the torn tendon must be assessed accurately. Overtensioning of the repair should be avoided. Bone-to-tendon fixation patterns must be modified according to tendon mobility.
- Failure to recognize tendon delamination can result in an incomplete tear repair. The deep aspect of the tear should be viewed from the lateral portal to identify deep tendon delamination and differential retraction.
- Tuberosity preparation should include roughening or light burring of the bone surface to facilitate bleeding. Crowding of anchors in the tuberosity can be minimized by removing prior suture anchors and utilizing lateral-row anchor placement on the lateral aspect of the tuberosity. Cases of extreme osteopenia of the greater tuberosity may require conversion to open techniques to augment fixation.
AUTHOR UPDATE:
For the past four years, we have preferred a suture-bridge (transosseous equivalent) technique for revision double-row repairs. The double-row repairs performed in the original study were traditional, with two rows of anchors located in the superior aspect of the tuberosity.