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Rotator cuff repair: Current concepts and applications
In this issue, we present part 2 of our two-part Round Table discussion on rotator cuff repair. In part 1, we addressed enhancing repairs through the use of surgical technique and biologics. In this installment we have asked our expert panel to share important pearls from their learning curve treating cuff tears as well as how they are applying the most recent research findings to their treatment.
Neal S. ElAttrache, MD
Moderator
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Neal S. ElAttrache, MD
Christopher S. Ahmad, MD
Stephen J. Snyder, MD
Stephen S. Burkhart, MDNeal S. ElAttrache, MD: Are there situations where you feel single-row suture configuration is optimal?
Christopher S. Ahmad, MD: Single-row suture repairs are best utilized for PASTA (partial articular surface tendon avulsion) repairs that are repaired with a transtendon technique. Tears that have limited mobility despite releases that do not allow the tendon edge to reach the lateral tuberosity are also repaired with a single-row technique.
Stephen S. Burkhart, MD: I prefer double-row or footprint repair whenever possible. However, if there has been some tendon loss (for example from prior failed surgery or infection) or if there is inadequate lateral excursion of the tendon to cover the footprint, even after appropriate releases, I will settle for single-row repair.
Stephen J. Snyder, MD: I use a single row of triple-loaded suture anchors in most all situations. I believe the best possible repair is one that has the maximum number of simple suture fixation passes through the tendon with no tension. If the tendon doesn’t heal, nothing else matters!
ElAttrache: What is the role of the rotator cuff cable in balancing the force couples of the shoulder and how do you manage the cable with your repair technique?
Burkhart: The “rotator cable” is an anatomic structure composed of fibers from the coracohumeral ligament. It transversely spans the distal attachments of the supraspinatus and infraspinatus tendons in a curving arc. We did a biomechanical study in the early 1990s which showed that the cuff attachments distal to the cable (the rotator crescent) were relatively stress-shielded. Furthermore, for cuff tears within the rotator crescent, the rotator cable behaved like the cable of a suspension bridge transmitting a distributed load from the cuff muscles to the cable attachments. Therefore it is very important to have the two ends of the rotator cable strongly fixed, even if the intervening rotator crescent tendon is not entirely repairable.
ElAttrache: Based upon biomechanical studies we have performed, it is clear that rotational shoulder motion and position produce variable strain magnitudes which are not uniformly distributed throughout the rotator cuff tendon. The anterior cable attachment has particularly concentrated forces under rotation. The application of this science to our repairs has led me to particular methods of repair depending on where the tear is located.
If the rotator cuff interval is involved in the tear, this generally indicates detachment of the anterior cable. This is generally the case if there is no remaining cuff attachment immediately lateral to the biceps at the very proximal groove on the anterior greater tuberosity. If this is the case, I directly repair the most anterior portion of the supraspinatus where it blends with the interval by placing an anchor adjacent to the articular surface of the humeral head just lateral and posterior to the biceps. I place a second anchor lateral to the proximal bicipital groove on the anterior edge of the greater tuberosity. I pass mattress sutures from the medial anchor and simple sutures from the lateral anchor through the most anterior fibers of the supraspinatus directly securing the anterior rotator cuff cable. This often immediately reduces the originally large tear into a crescent- or U-shaped tear and gives it direct and secure fixation where the highest rotational forces are concentrated. I then proceed with a suture-bridge repair of the remainder of the supraspinatus and infraspinatus as necessary. I do this cable reattachment prior to any margin convergence as well since it brings the supraspinatus out to proper length.
ElAttrache: What is the sequence of your repair strategy for large tears?
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Ahmad: I initially perform diagnostic arthroscopy with a standard posterior portal. After glenohumeral inspection, the camera is introduced in subacromial space. A lateral working portal is made at the anterior edge of the acromion and 2-cm lateral. Bursectomy and initial greater tuberosity debridement is performed. The camera is then introduced into the subacromial space with a new portal 1 cm lateral to the posterior edge of the acromion to better visualize the tear and tuberosity.
Releases are performed as necessary using the lateral working portal. The tear configuration is appreciated. The tuberosity is abraded thoroughly to stimulate healing. The arm is then adducted to bring the medial tuberosity to a better angle for medial row anchor insertion. An anchor is then placed percutaneously in the anterior footprint adjacent to the cartilage. The arm is then placed in 30° abduction and all four strands of the double-loaded suture anchor are passed with the sutures controlled in the standard anterior cannula. Then sutures are passed with emphasis on reducing the tendon to the footprint anatomically. The arm is abducted and internally rotated and a second medial row anchor is placed in the posterior aspect of the footprint adjacent to the articular cartilage. Suture passing is then performed for all four strands and the sutures are retrieved from the posterior cannula.
Knot tying takes place typically from posterior to anterior. Suture bridges are then created by abducting the shoulder to 45° and with external rotation. Three sutures are retrieved out the lateral cannula and the Pushlock anchor (Arthrex Inc.) is placed lateral and anterior in the greater tuberosity. The arm is then internally rotated and the second Pushlock is placed with three additional suture bridges. This completes the repair. Subacromial decompression is performed as necessary.
Burkhart: I always repair the subscapularis first, because that is the most difficult area to visualize and because its upper attachment point helps define the rotator cable to make subsequent fixation of the supraspinatus and infraspinatus easier. My next step is to do a biceps tenodesis (if indicated) with an interference screw. After that, I repair the remaining cuff tear. For crescent-shaped tears, I first place the medial anchors, then do antegrade suture passage, then place my lateral anchors to secure the suture bridge. For large U-shaped tears and for chronic L-shaped tears, I first place side-to-side margin convergence sutures and then place anchors to secure the tendon to bone. For short U-shaped tears, I use a “margin-convergence-to-bone” technique, in which the sutures from the anchor are passed as side-to-side sutures to achieve simultaneous margin convergence and tendon-to-bone fixation.
Snyder: I always start by shaving the footprint and the undersurface of the cuff from both the anterior and posterior portals on the glenohumeral side. This allows me to visualize the under-side of the cuff and evaluate any deep tear extensions that can’t be appreciate from the top. After bursal side releases and debridement, I perform a trial cuff reduction using a grasping tool while viewing from the lateral (50 yard line) portal. I then perform any side-to-side stitches that are necessary; tying each suture after it is passed. If the tendon edge is degenerative or frayed, I will place and tie one or more “rip-stop” stitches. I always temporarily insert a 3-mm metal rod under the suture while tying it to ensure the knots are not excessively tight, causing bunching of the tendon.
I then insert triple-loaded suture anchors. The first anchor is placed 5 mm from the posterior edge of the tear adjacent to the articular cartilage at a 45º (tent peg or dead-man) angle in a medial direction below the strong subchondral bone. All three sutures are passed using various curved suture hooks and shuttle techniques. Each suture pair is stored in a different colored miniature plastic tube (Suture Savers, ConMed Linvatec) outside the posterior cannula. Additional anchors are inserted from posterior to anterior until the edge is completely fixed. The scope is moved to either the anterior or posterior portal for visualization as the suture pairs are retrieved and tied through the lateral portal.
ElAttrache: Are there rotator cuff tears that you feel should not be repaired arthroscopically?
Ahmad: The major advantages of arthroscopic rotator cuff repair compared to open rotator cuff repair are improved visualization, improved releases and tendon mobilization, and decreased injury to the deltoid. Therefore, I have favored arthroscopic repair for all repairable tears.
For irreparable tears in young patients, open muscle transfers such as latissimus dorsi for supraspinatus and infraspinatus tears and pectoralis major transfer for subscapularis tears are considered. For older patients with irreparable rotator cuff tears and glenohumeral arthritis, I prefer reverse total shoulder arthroplasty to achieve greater predictable pain relief and function.
Burkhart: My experience has been that 97% of all rotator cuff tears are fully repairable by arthroscopic means. The other 3% are generally amenable to partial repair by arthroscopic techniques. I should point out that there was no arthroscopic cuff repair for the first several years of my career, so that all of my early experience was with open repair. Therefore, I have the advantage of having lived through all the challenges of both open and arthroscopic cuff repairs. I can assure you that properly-executed arthroscopic cuff repairs are vastly superior to open repairs in every way.
Snyder: I believe that if a tear cannot be repaired arthroscopically, it cannot be repaired open. The important deltoid muscle must be protected at all costs especially when the cuff cannot be repaired.
ElAttrache: What are the three most important pearls from your experience that you recommend for arthroscopic rotator cuff repair?
Ahmad: Pearl number one: Recognize that every rotator cuff tear is unique and has its own personality. Spend time to recognize the tear pattern and the mobility of the tear.
Pearl number 2: Create a plan of repair to create a tension-free repair that avoids areas of stress overload on the tendon. This requires performing adequate releases, appreciating what aspects of the tendon edges need to be repaired to which areas of the greater tuberosity to create even stress distribution across the repair.
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Pearl number 3: Once you have your repair plan, execute the plan quickly and with all necessary equipment ready to avoid bursal swelling and poor visualization that may take place when surgery time becomes lengthy.
Burkhart: First, carefully examine the subscapularis for tears. A nonretracted tear of the upper subscapularis is a subtle but critical diagnosis to make, and it will be symptomatic if it is not repaired.
Second, spend time understanding the cuff tear pattern and repair it anatomically to its footprint.
Third, always think two steps ahead during the repair. This will make you more efficient. Arthroscopic cuff repair is a lot like pool — with each shot, a good player is always setting up his next shot.
Snyder: Attach the cuff to bone with as little tension as possible. Use multiple polyethylene sutures (three preferably) in each anchor. Release nature’s “magic tonic,” the bone marrow, from the tuberosity to add stem cells, growth factors and vascular access channels to enhance healing.
For more information:
- Christopher S. Ahmad, MD, associate professor of orthopedic surgery, Columbia University, Center for Shoulder, Elbow and Sports Medicine, can be reached at 622 W. 168th St., New York, NY 10032; 212-305-5561; e-mail: csa4@columbia.edu. He has received grant research support from Arthrex Inc.
- Stephen S. Burkhart, MD, can be reached at The Orthopaedic Institute, 400 Concord Plaza Drive, Suite 300, San Antonio, TX 78216; 210- 489-7220; e-mail: sburkhart@satx.rr.com. He receives institutional or research support, royalties from, and is a consultant for Arthrex Inc.
- Neal S. ElAttrache, MD, can be reached at Kerlan-Jobe Orthopaedic Clinic, 6801 Park Terrace Drive, Suite 500, Los Angeles, CA 90045-1539; 310-665-7257; e-mail: elattrache@aol.com. He is a consultant to Arthrex Inc. for patented product development.
- Stephen J. Snyder, MD, can be reached at the Southern California Orthopedic Institute, 6815 Nobel Ave., Van Nuys, CA 91405; 818-901-6600; e-mail: sjsscoi@yahoo.com. He receives institutional or research support, royalties, stock options from, and is a consultant for Wright Medical Technology Inc. and Conmed Invatec. He receives funding and royalties from, and is a consultant for Smith & Nephew and receives institutional or research funding and royalties from DJO, Sawbones/Pacific Research Laboratories. He receives funding from Arthrex. He also receives institutional or research funding from DePuy, a Johnson & Johnson Company and is a consultant for Arthrex, Lippincott and Stryker Orthopaedics.