Principles of Arthroscopic Principles of Arthroscopic Rotator Cuff RepairRotator Cuff Repair

Edward Tillett, M.D.Department of Orthopedic Surgery University of Louisville

Principles of Arthroscopic Principles of Arthroscopic Rotator Cuff RepairRotator Cuff Repair

Adequate VisualizationAdequate Visualization

Rotator cuff preparation prior to repairRotator cuff preparation prior to repair

Appropriate portal placement for suture Appropriate portal placement for suture passage and suture anchor placementpassage and suture anchor placement

Secure knot tying Secure knot tying

Adequate VisualizationAdequate Visualization

Techniques to minimize bleedingTechniques to minimize bleeding

Adequate subacromial bursectomyAdequate subacromial bursectomy

Subacromial decompressionSubacromial decompression

Techniques to Minimize BleedingTechniques to Minimize Bleeding

Adequate distension of subacromial spaceAdequate distension of subacromial space Gravity inflow or arthroscopic pumpGravity inflow or arthroscopic pump

Anaesthesia to keep blood pressure Anaesthesia to keep blood pressure normotensive or belownormotensive or below

Adequate Subacromial BursectomyAdequate Subacromial Bursectomy

Anatomy of subacromial bursaAnatomy of subacromial bursa

Adequate Subacromial BursectomyAdequate Subacromial Bursectomy

The bursectomy needs to be anterior, The bursectomy needs to be anterior, posterior, distal. posterior, distal. Must see the entire rotator cuffMust see the entire rotator cuff Must see the insertion of the rotator cuff onto Must see the insertion of the rotator cuff onto

greater tuberositygreater tuberosity

Resection: Camera and shaver must be Resection: Camera and shaver must be switched between posterior and lateral switched between posterior and lateral portal portal

Portals for Subacromial Portals for Subacromial BursectomyBursectomy

Posterior Portal: Posterior Portal: standard posterior portal used for standard posterior portal used for

glenohumeral joint inspection: 2cm distal and glenohumeral joint inspection: 2cm distal and medial to posterolateral border of acromiummedial to posterolateral border of acromium

Lateral Portal:Lateral Portal: 3 fingerbreadths distal from the anterolateral 3 fingerbreadths distal from the anterolateral

border of the acromiumborder of the acromium

Portals for Subacromial BursectomyPortals for Subacromial Bursectomy

Arthroscopic VisualizationArthroscopic Visualization

Anterior subacromial bursaAnterior subacromial bursa

Posterior subacromial bursaPosterior subacromial bursa

Subacromial DecompressionSubacromial Decompression(if necessary)(if necessary)

Cutting Block TechniqueCutting Block Technique

Camera in lateral portalCamera in lateral portal

Shaver in posterior portal Shaver in posterior portal

Prepare Tear for RepairPrepare Tear for Repair

Identify type of rotator cuff tearIdentify type of rotator cuff tear

Mobilize tear through soft tissue releasesMobilize tear through soft tissue releases

Mobilize tear through marginal Mobilize tear through marginal convergence suturesconvergence sutures

Identify Rotator Cuff TearIdentify Rotator Cuff Tear

U-shaped tearU-shaped tear

Crescentic-shaped repairCrescentic-shaped repair

L-shaped tearL-shaped tear

Mobilize Tear through Soft Tissue Mobilize Tear through Soft Tissue ReleasesReleases

Resect soft tissue above and below tearResect soft tissue above and below tear

Release of coracohumeral ligament at Release of coracohumeral ligament at base of coracoidbase of coracoid

Release of infraspinatus/supraspinatus Release of infraspinatus/supraspinatus interval in line with scapular spineinterval in line with scapular spine

Mobilize Rotator Cuff through Mobilize Rotator Cuff through Marginal Convergence SuturesMarginal Convergence Sutures

Appropriate for U-shaped tearAppropriate for U-shaped tear

Principle is to do a side to side tendon Principle is to do a side to side tendon repair in an anterior to posterior directionrepair in an anterior to posterior direction Lateralize the tendon towards the greater Lateralize the tendon towards the greater

tuberosity tuberosity Take tension off the repair to the greater Take tension off the repair to the greater

tuberositytuberosity

Mobilize Rotator Cuff through Mobilize Rotator Cuff through Marginal Convergence SuturesMarginal Convergence Sutures

Mobilize Rotator Cuff through Mobilize Rotator Cuff through Marginal Convergence SuturesMarginal Convergence Sutures

Portals for Suture TechniquePortals for Suture Technique

Portal location is about periphery of Portal location is about periphery of acromium acromium

Dependent upon the location of the tear Dependent upon the location of the tear and the type of suture retrieval device and the type of suture retrieval device being used.being used.

Technique of Suture Anchor Technique of Suture Anchor PlacementPlacement

Ideal angle of suture anchor is 45Ideal angle of suture anchor is 45° relative ° relative to the long axis of the humerus.to the long axis of the humerus.

Placement of suture anchor is as close to Placement of suture anchor is as close to greater tuberosity as possible.greater tuberosity as possible. Should not repair the tendon under too much Should not repair the tendon under too much

pressure, therefore, a medialized location pressure, therefore, a medialized location may be necessary.may be necessary.

Technique of Suture Anchor Technique of Suture Anchor PlacementPlacement

Sometimes, the medial and lateral Sometimes, the medial and lateral attachments of the rotator cuff are both attachments of the rotator cuff are both repaired (double-row repair)repaired (double-row repair)

Portals for Suture Anchor Portals for Suture Anchor PlacementPlacement

Portal placement is verified with a spinal Portal placement is verified with a spinal needleneedle

The needle is directed at 45The needle is directed at 45° to the ° to the humerus and close to the tendon tear humerus and close to the tendon tear where the repair is necessarywhere the repair is necessary

The site of portal location varies about the The site of portal location varies about the rim of the anterolateral aspect of the rim of the anterolateral aspect of the acromium. acromium.

Portals for Suture Anchor Portals for Suture Anchor PlacementPlacement

Secure Knot TyingSecure Knot Tying

Sliding or half hitch knotsSliding or half hitch knots

Knot SecurityKnot Security

Loop SecurityLoop Security

Example of Arthroscopic Rotator Example of Arthroscopic Rotator Cuff RepairCuff Repair