Principles of Arthroscopic Rotator Cuff Repair

1. Principles of Arthroscopic Rotator Cuff Repair Edward Tillett, M.D. Department of Orthopedic Surgery University of Louisville

2. Principles of Arthroscopic Rotator Cuff Repair • Adequate Visualization • Rotator cuff preparation prior to repair • Appropriate portal placement for suture passage and suture anchor placement • Secure knot tying

3. Adequate Visualization • Techniques to minimize bleeding • Adequate subacromial bursectomy • Subacromial decompression

4. Techniques to Minimize Bleeding • Adequate distension of subacromial space • Gravity inflow or arthroscopic pump • Anaesthesia to keep blood pressure normotensive or below

5. Adequate Subacromial Bursectomy • Anatomy of subacromial bursa

6. Adequate Subacromial Bursectomy • The bursectomy needs to be anterior, posterior, distal. • Must see the entire rotator cuff • Must see the insertion of the rotator cuff onto greater tuberosity • Resection: Camera and shaver must be switched between posterior and lateral portal

7. Portals for Subacromial Bursectomy • Posterior Portal: • standard posterior portal used for glenohumeral joint inspection: 2cm distal and medial to posterolateral border of acromium

8. Portals for Subacromial Bursectomy • Lateral Portal: • 3 fingerbreadths distal from the anterolateral border of the acromium

9. Arthroscopic Visualization • Anterior subacromial bursa • Posterior subacromial bursa

10. Subacromial Decompression(if necessary) • Cutting Block Technique • Camera in lateral portal • Shaver in posterior portal

11. Prepare Tear for Repair • Identify type of rotator cuff tear • Mobilize tear through soft tissue releases • Mobilize tear through marginal convergence sutures

12. Identify Rotator Cuff Tear • U-shaped tear • Crescentic-shaped repair • L-shaped tear

13. Mobilize Tear through Soft Tissue Releases • Resect soft tissue above and below tear • Release of coracohumeral ligament at base of coracoid • Release of infraspinatus/supraspinatus interval in line with scapular spine

14. Mobilize Rotator Cuff through Marginal Convergence Sutures • Appropriate for U-shaped tear • Principle is to do a side to side tendon repair in an anterior to posterior direction • Lateralize the tendon towards the greater tuberosity • Take tension off the repair to the greater tuberosity

15. Mobilize Rotator Cuff through Marginal Convergence Sutures

16. Mobilize Rotator Cuff through Marginal Convergence Sutures

17. Portals for Suture Technique • Portal location is about periphery of acromium • Dependent upon the location of the tear and the type of suture retrieval device being used.

18. Technique of Suture Anchor Placement • Ideal angle of suture anchor is 45° relative to the long axis of the humerus. • Placement of suture anchor is as close to greater tuberosity as possible. • Should not repair the tendon under too much pressure, therefore, a medialized location may be necessary.

19. Technique of Suture Anchor Placement • Sometimes, the medial and lateral attachments of the rotator cuff are both repaired (double-row repair)

20. Portals for Suture Anchor Placement • Portal placement is verified with a spinal needle • The needle is directed at 45° to the humerus and close to the tendon tear where the repair is necessary

21. Portals for Suture Anchor Placement • The site of portal location varies about the rim of the anterolateral aspect of the acromium.

22. Secure Knot Tying • Sliding or half hitch knots • Knot Security • Loop Security

23. Example of Arthroscopic Rotator Cuff Repair