ARTHROSCOPIC ROTATOR CUFF REPAIR

T. Andrew Israel, MDLuther Midelfort Orthopaedic &

Sports Medicine Center

OPERATIVE MANAGEMENT OF ROTATOR CUFF TEARS

• Treatment Options

• Treatment Principles

• Surgical Indications

• Advantages of ARCR

• Disadvantages of ARCR

• Technique for ARCR

• Results

TREATMENT OPTIONS

• ASAD/debridement without repair

• Open repair

• Mini-open repair

• Arthroscopic repair

TREATMENT PRINCIPLES

• Address associated pathology

• Adequate decompression• Assess tear-size, retraction, pattern, tissue

quality, repairability

• Tendon mobilization

• Secure repair

• Supervised rehabilitation program

SURGICAL INDICATIONS

• Pain

• Functional deficits

• Failure to respond to nonoperative care

• Full-thickness tear

• Extensive partial-thickness tear

• Acute injury

ADVANTAGES OF ARCR

• See both sides of cuff• Visualize all pathology-labral tears, biceps,

OA, etc.

• Easier releases(esp. capsule)

• Less pain, morbidity

• Smaller scars

• Better ROM

• PATIENTS WANT IT!

DISADVANTAGES OF ARCR

• Learning curve

• ? Smaller contact area with bone for healing

• High retear rate by ultrasound reported

• ? Pain from resorption of anchors

• Coding/reimbursement problems

TECHNIQUE FOR ARCR

• Define tear• Mobilize tendons• Prepare tuberosity• Cuff reduction• Place anchors• Suture management• Pass sutures through tear edge• Knot tying

DEFINE TEAR

• View from anterior and from posterior

• Measure with probe known size

• Trim ragged edges but preserve tissue

MOBILIZE TENDONS

• Place retention sutures

• Release capsule

• Anterior interval release

• Posterior interval release

PREPARE TUBEROSITY

• Remove excrescences but preserve cortex

• Trim tendon stump

• Define footprint

MARGIN CONVERGENCE

• Begin cuff reduction

• Work medial to lateral

• Side to side sutures

• Tie knots

PLACE ANCHORS

• At lateral aspect of footprint

• Metal or biodegradable

• Make sure well fixed in bone

SUTURE MANAGEMENT

• Keep track of portals

• Avoid tangles

• Think one step ahead

• Move at steady pace

PASS SUTURES THROUGH TEAR EDGE

• Many devices available

• Avoid tearing tendon

• Line up puncture with anchor

KNOT TYING

• Perfect knots

• Perfect knots

• Flawlessly perfect knots

RESULTS Gartsman, JBJS, 1998

• 73 arthroscopic RCR

• Average age 60.7 yrs

• All pts followed at least 2 yrs(30 mons)

• 78% G/E relief of pain

• 90% G/E satisfaction

• None of the shoulders were rated G/E preop, 84% G/E @ most recent f/u

RESULTS Burkhart, Arthroscopy, 2001

• 59 arthroscopic RCR

• Average follow-up 3.5 yrs

• 95% G/E result regardless of tear size

• Rapid return overhead function(4 mons)

CASE PRESENTATION

CASE D.E.

• 53 male RHD farmer

• Left anterior shoulder pain x 2 years

• No prior injury or surgery

• Nonoperative Rx including PT, NSAIDS, injections, activity modifications, etc.

PHYSICAL EXAM

• Crepitus with PROM

• Tenderness greater tuberosity

• AROM 155/170, 55/75, L5/T10

• 3/5 power abduction & external rotation

• Positive impingement tests

SHOULDER ANATOMY

SURGERY

SUMMARY

• Much recent enthusiasm regarding complete arthroscopic rotator cuff repair

• For many, this newer technique may be preferable alternative to more traditional mini-open rotator cuff repair

• Important that basic principles of rotator cuff repair not be compromised

SUMMARY

• Several short-term studies demonstrate excellent results comparable with those of traditional techniques

• Choice of procedure based on variety of considerations, including patient expectations, pathoanatomy of the cuff, and arthroscopic skills of the surgeon