ARTHROSCOPIC ROTATOR CUFF REPAIR MARK A. NEAULT, MD, and CARLOS A. GUANCHE, MD
The use of the arthroscope to address shoulder pathology is continuously evolving. Many aspects of shoulder arthroscopy are readily accepted and used by orthopedic surgeons, but some procedures can be technically difficult. Arthroscopic rotator cuff repair has traditionally involved the use of cumbersome knot tying techniques, deterring many surgeons from using this technique. Although open and mini-open rotator cuff repair is commonly used with predictable results, there still remains inherent morbidity to any open technique. This article will outline a technique that avoids knot tying and suture management in arthroscopic rotator cuff repair. Although the indications are evolving, arthroscopic rotator cuff repair allows predictable results with excellent pain relief and return to function. KEY WORDS: arthroscope, rotator cuff repair Copyright 2002, Elsevier Science (USA). All rights reserved.
The application of shoulder arthroscopy has expanding indications. Although open procedures remain the gold standard for many shoulder operations, they are not without morbidity. Specifically looking at open 1,2 and miniopen s rotator cuff repair, the deltoid is the most commonly injured area. Deltoid detachment, muscle tissue damage, and scarring are common problems. 4 In addition, arthrofibrosis and significant pain can affect many patients. 4 Arthroscopy has become a more universally accepted approach in addressing subacromial impingement, acromioclavicular joint arthrosis, and superior labral anterior posterior (SLAP) lesions. More recently, all-arthroscopic procedures have been described to treat full-thickness rotator cuff pathology, s Advantages of an arthroscopic approach to rotator cuff pathology include small incisions, limited deltoid injury, glenohumeral joint inspection, ability to address intra-articular pathology, limited soft tissue dissection, less pain, and rapid rehabilitation. Studies using suture anchors with an all-arthroscopic technique have shown promising results. 6-9 Technical difficulties of shoulder arthroscopy seem to limit its use in many settings. Arthroscopic knot tying is a technique that requires experience and patience. The Headed Bio-Corkscrew (HBC; Arthrex Inc, Naples, FL) is made from PLDLA (Poly[L-lactide-co-D,L-lactide]) and is a device that avoids the use of sutures altogether (Fig 1). In the senior author's experience, arthroscopic rotator cuff repair using the HBC has provided predictable results with less technical limitations. Patients have found pain relief to be excellent and return to function to be rapid. Postoperative magnetic resonance imaging (MRI) indicates that this product made from PLDLA is resorbed completely by the body, leaving little evidence of its use.
From the Minneapolis Sports Medicine Center, Minneapolis, MN. Address reprint requests to Carlos A. Guanche, MD, Minneapolis Sports Medicine Center, 701 25th Ave S, Suite 400, Minneapolis, MN 55454. E-mail:
[email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 1060-1872/02/1002-0001 $35.00/0 doi:l 0.1053/otsm.2002.30171
As a bioactive material, it results in no detectable inflammatory response on follow-up MRI. Additionally, there is no need for concern with the quality of follow-up MRI, because there is no residual implant to interfere.
INDICATIONS The indications for arthroscopic rotator cuff repair are still evolving. With open procedures as the gold standard, the same treatment principles should be applied to the arthroscopic approach. Although the literature seems to focus on smaller tears, it has been mentioned and seems feasible to address larger tears. The reducibility of the rotator cuff tear is a more limiting factor than the size of the tear. This same principle applies to open procedures. An appropriate candidate for arthroscopic repair should have a tear that (1) is reducible to within 5 mm of the anatomic origin, 6 (2) can be pulled lateral to the articular surface with a moderate amount of tension after mobilization,9 or (3) is less than 2 cm in size s (Fig 2). The upper limit of tear size is still in question. As with open rotator cuff repair, it is important that a 6- to 12-month period of conservative management be exhausted before operative consideration. In any case, the surgeon should be prepared to convert to a mini-open or traditional open procedure should the repair be compromised in any way. In these procedures, time is of the essence. In the authors' opinion, if a successful repair is not completed in less than an hour, then further attempts will impair visualization as a result of soft tissue swelling from the arthroscopic fluid. This swelling may eventually compromise the surgeon's ability to easily perform any open repair.
OPERATIVE
TECHNIQUE
Positioning Beach chair position is our preference; however, the lateral position would be equally applicable. Beach chair positioning may allow for easier conversion to a mini-open
Operative Techniques in Sports Medicine, Vol 10, No 2 (April), 2002: pp 93-98
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procedure if necessary. Before beginning the procedure, the subacromial space is distended with 25 mL of 0.5% Marcaine with epinephrine. This offers improved postoperative pain management. A fluid inflow pump is used to assist with hemostasis and improve visualization. Portals
The standard posterior portal, which is 1.5 to 2 cm inferior and medial to the posterolateral corner of the acromion, is usually too low. A slightly more superior posterior portal (by 1 cm) allows better visualization of the subacromial space while performing the rotator cuff repair. The standard anterior portal is established for the glenohumeral arthroscopy and is used for probing or occasionally for fluid inflow while working in the subacromial space. The initial lateral portal is established approximately 2 cm distal to the acromion, at the unction of the anterior and middle thirds. Most of the time, an accessory lateral portal is established for anchor insertion. This is dictated by the cuff tear, but in general, is at the anterolateral corner of the acromion and often adjacent to it. The arthroscope can and should be moved between portals to obtain better visualization of the entire pathology. It is not unusual to use all three portals (anterior, posterior, and lateral) for visualization during any given case. Additionally, bearing in mind the anatomy of the shoulder and specifically, the axillary nerve, essentially any area around the shoulder from anterior to posterior can serve as an accessory portal, as long as the placement is kept within 5 cm of the border of the acromion. The morbidity from several accessory portals is minimal. However, the morbidity from a poorly placed anchor may be large. Full-thickness Rotator Cuff Tears Inspection and Tear Classification. The g]enohumeral joint is entered and inspected. Once the rotator cuff is
Fig 1. (A) Headed Bio-Corkscrew device (Arthrex Inc, Naples, FL). (B) Instrumentation for device insertion. From right to left: cannulated tap, cannulated spear with guide wire in place, calibrated torque wrench, guide wire securing device. Fig 2. Preoperative arthroscopic view of a rotator cuff tear (right shoulder, posterior portal view).
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visualized, an arthroscopic grasper is inserted via the lateral portal and is used to assess mobility and dimensions of the tear. If the disruption meets the previously mentioned criteria, then an arthroscopic repair is indicated. The tear must be visualized from both the glenohumeral joint and the subacromial space to completely assess the size and type of tear. Simple avulsions (crescent type) are managed in a straightforward manner with reattachment to the greater tuberosity. More complex patterns, including "U-shaped" and "L-shaped" tears, may benefit from the use of sutures to bring the margins together in a side-to-side fashion. This approach has been termed margin convergence and has been shown to significantly reduce the tension on the tendon-bone repair site3 ° A suture passing-retrieval instrument, such as the Penetrator (Arthrex Inc, Naples, FL), may simplify this technique. The arthroscope is then placed into the subacromial space (from the posterior portal) and the shaver is introduced laterally. Any remaining devitalized tissue is debrided and a complete bursectomy is performed to increase visualization of the rotator cuff. A combination of a shaver and an electrothermal device, such as the Turbovac (Arthrocare Inc, Sunnyvale, CA) is effective in performing a hemostatic bursectomy. Rotator Cuff Mobilization. Mobilization of the rotator cuff begins with a complete bursectomy. If necessary, the coracohumeral ligament may be released. The coracohumeral ligament is visualized after complete debridement of the fatty tissue underneath the acromioclavicular joint. Because this area is highly vascular, complete cauterization of all tissue is essential to maintain visualization. Release of the coracohumeral ligament may be facilitated by applying tension to the rotator cuff from the lateral portal, while the cautery device is inserted anterior to release the ligament. In some cases, an intra-articular release of the interface between the superior capsule and the supraspinatus tendon may be required. A blunt dissector is an effective way of performing this maneuver. No significant mobilization is carried more than 1.5 cm medial to the glenoid articular surface, so as to avoid damage to the suprascapular nerve. Repair Site Preparation. The greater tuberosity is assessed for adequate vascularity. In some cases (especially in younger patients), a burr is used to minimally decorticare the desired area of reattachment down to bleeding bone. No formal trough is created. In most cases, simple abrasion with a shaver will allow sufficient exposure of a bleeding bed (Fig 3). Acromioplasty. The decision to perform an acromioplasty
is made at this point. In some cases, a thickened coracoacromial ligament precludes visualization of the lateral aspect of the humerus. In this situation, the coracoacromial ligament is released with the use of a shaver a n d / o r electrothermal device. Bony resection, if indicated, should be reserved until after the rotator cuff repair is completed. This avoids any bony bleeding, which may impair visualization of the rotator cuff. ARTHROSCOPIC ROTATOR CUFF REPAIR
Fig 3. Diagrammatic representation of debrided greater tuberosity with relatively flat greater tuberosity area~
Repair. The HBC allows watertight repair of the rotator cuff without the use of sutures. Implantation of the HBC is performed with the arthroscope posterior and in the subacromial space. A grasper is used through the lateral portal to reduce the cuff to its anatomic position (or to a previously decided position). Particular attention is paid toward grasping both portions of any delaminating tears. If grasping the tissue impairs visualization or there is any question of being able to grasp all portions of a delaminating tear, then consideration should be made to use a suture passing-retrieval instrument. When necessary, this instrument allows the passing of 1 or more sutures through the lateral portion of the cuff and then serves as a traction device to reduce the cuff while a guide wire and HBC are being advanced. An accessory portal is created to insert the HBC. As mentioned previously, this portal is typically located slightly anterior and medial to the standard lateral portal and is first localized with a spinal needle. Both needle position a n d / o r rotation of the humerus will optimize the location of the portal. This ability to rotate the arm is critical, yet often overlooked. Abduction should be limited to minimize the tension on the repair. The guide wire for the HBC is then drilled through the cuff tissue (Fig 4), after using the soft tissue spear to stabilize the tissue. Three technical points require special consideration. First, there should be enough tissue lateral to the guide wire (approximately 5 to 7 mm) to ensure that the tap and HBC will not cut out during the process of implantation or immediately thereafter. Second, the guide wire should be inserted perpendicular to the area of the greater tuberosity to ensure best fixation of the cuff and to prevent one shoulder of the HBC from engaging the tuberosity before complete seating of the implant. This avoids mechanical problems with impingement between the device and the underside of the acromion. Third, the guide wire should be inserted with the arm at the side so as to avoid undue tension on the rotator cuff tissue. Once placement of the guide wire is confirmed, the cam~ulated tap is inserted, followed by the HBC device 95
Physical therapy begins within the first 3 days. Passive motion is allowed for the first 6 weeks, and as indicated previously, the degree of limitation is dictated by the intraoperative examination after cuff stabilization. Active strengthening begins after 6 weeks, followed by full, unrestricted activity at 3 months. This unrestricted activity is predicated on full active and passive range of motion, as well as normal strength of the musculature.
RESULTS
Fig 4. Guide wire positioned through rotator cuff using cannulated spear. Note use of the rotator cuff spear and the relatively perpendicular orientation of the guide wire to the greater tuberosity.
We examined 11 patients at an average follow-up of 12.6 months (range 9 to 16 months) after undergoing an arthroscopic rotator cuff repair with the HBC. The American Shoulder and Elbow Surgeons' (ASES) questionnaire, 11 a complete physical assessment, and a follow-up MRI examination were performed for evaluation. The preoperative ASES scores averaged 39.6 (range 16 to 75) compared with the postoperative average ASES score of 82 (range 73 to 99). The visual analog pain component showed an initial average score of 6.9 (range 4 to 9) with 10 patients in the severe category and 1 in the moderate category. Fol-
(Fig 5). The insertion device includes a calibrated torque wrench that is tensioned to 4 in-lb of torque. This ensures maximum purchase of the HBC in the rotator cuff and humerus, while preventing breakage of the implant (Fig 6). After complete insertion of the HBC, the glenohumeral joint is entered once again for evaluation of the reapproximarion of the cuff (Fig 7). Any visualization of the subacromial space from this position may indicate the need for additional anchors either anterior or posterior to the initial HBC. Any insecurity in this regard may be confirmed by visualizing the area from the lateral portal. In the senior author's experience, 1 HBC per centimeter of anterior to posterior tearing is adequate for anatomic and watertight closure. This concept is derived from the literature on suture anchors? After completion of the repair, any requirement for acromial resection or distal clavicle resection may be addressed in an arthroscopic or open fashion, as desired. The final step in the procedure is the assessment of the repair. The arm is taken through a range of motion and cuff tension is evaluated concurrently. Based on this assessment, the physical therapy regimen is altered, if necessary. In general, full passive range of motion is the goal; however, occasionally tension in the repair above a certain degree of motion will preclude this. In those cases, passive range of motion in the acute postoperative period should be limited to 10 ° less than the degree of motion that causes undue tension. These limitations are maintained for 6 weeks.
POSTOPERATIVE MANAGEMENT A shoulder Cryo-cuff (Aircast, Summit, NJ) is applied for both cold therapy and to serve as a sling. The patient is discharged home (outpatient procedure) with a simple sling to use when the Cryo-cuff is no longer needed. 96
Fig 5. (A) Diagrammatic subacromial view of implant insertion. (B) Coronal diagrammatic view of implant in place. NEAULT AND GUANCHE
Fig 7. Arthroscopic view of completed repair (right shoulder, viewed from posterior portal).
Fig 6. (A) Arthroscopic view of completed cuff repair with guide wire still in place (right shoulder, viewed from posterior portal). (B) Diagrammatic representation of cuff repair with HBC in place.
difficulties of knot tying and suture passage. On some level, the arthroscopic indications are still evolving; however, the fundamentals are the same as for open procedures. Conservative m a n a g e m e n t is still the mainstay of treatment before surgical intervention. As with o p e n repairs, the size of the tear does not seem to be as important as the reducibility of the cuff. Tears larger than 3 cm 2 are certainly more difficult to m a n a g e arthroscopically, and a failure to recognize this and not convert to an open or mini-open p r o c e d u r e m a y be one of the major factors leading to failure of an arthroscopic repair. 9 In one study, the perioperative factors associated with a p o o r outcome were the difficulty of reduction of the rotator cuff to its anatomic insertion, the subjective solidity of the repair as interpreted b y the surgeon, and reattachment of the cuff to a near-anatomic position. 12 The advantages of products such as the HBC are many. By eliminating the use of sutures, it makes the arthro-
low-up scores a v e r a g e d 1.1 (range 0 to 2), with all 11 patients in the minimal-to-no-pain category. In the physical assessment, preoperative f o r w a r d flexion averaged 148 ° (range 80 ° to 170 °) and abduction averaged 141 ° (range 80 ° to 170°). This is c o m p a r e d with postoperative f o r w a r d flexion, which averaged 161 ° (range 145 ° to 170°), and abduction, which averaged 162 ° (range 150 ° to 170°). Postoperative MRI examination indicated progressive dissolution of the HBC, with the 2 patients w h o were 15 and 16 m o n t h s from surgery having no visible evidence of the implanted devices (Fig 8). There w e r e also no areas of inflammation n o t e d on postoperative MRI. In addition, the rotator cuff tissues s e e m e d progressively more normal with increasing follow-up.
DISCUSSION Arthroscopic rotator cuff repair is not a n e w concept; h o w e v e r , the introduction of sutureless devices avoids the ARTHROSCOPIC ROTATOR CUFF REPAIR
Fig 8. Coronal MRI image of patient 14 months after arthroscopic rotator cuff repair with Headed Bio-Corkscrew. 97
scopic a p p r o a c h to rotator cuff p a t h o l o g y technically m o r e feasible. In addition, the p r o d u c t is c o m p l e t e l y absorbable a n d m a d e f r o m PLDLA, resulting in no i n f l a m m a t o r y reaction. This is s u p p o r t e d b y the findings on f o l l o w - u p MRI, w i t h no e v i d e n c e of residual material b y 12 to 14 months. S h o r t - t e r m results indicate no m o r b i d i t y f r o m either i m p l a n t b r e a k a g e or degradation. After a successful surgical p r o c e d u r e a n d a s t a n d a r d t h e r a p y protocol, the result is a s h o u l d e r w i t h excellent function, m i n i m a l l y visible incisions, a n d no r e m a i n i n g implants. O u r results s u p p o r t predictable outcomes, w h i c h relieve p a i n a n d functional limitations f o u n d in the rotator cuff-deficient patient. Follow-up MRI also s h o w s p r o g r e s s i v e healing of rotator cuff tissue as the p o s t o p e r a t i v e p e r i o d progresses. In a n y event, the technical aspects of the p r o c e d u r e are i m p o r t a n t to consider. Arthroscopic repair of the rotator cuff can be technically difficult a n d requires a significant a m o u n t of arthroscopic skill, especially w i t h larger tears. The mobilization of the tissue, d e b r i d e m e n t of the tear, a n d s u b s e q u e n t anchor p l a c e m e n t are all integral portions of the repair that m u s t be m a s t e r e d to achieve consistent results. The ability to recognize that the repair m a y be c o m p r o m i s e d if not d o n e in an o p e n or m i n i - o p e n fashion is e x t r e m e l y important. In s u m m a r y , the arthroscopic m a n a g e m e n t of rotator cuff tears is a viable p r o c e d u r e w i t h indications that are still evolving. There are m a n y techniques a n d p r o d u c t s available to achieve repair of the rotator cuff. O u r preferred technique uses the sutureless HBC. N o t only is this technique easier, b u t it affords predictable outcomes. Presently, as long as the cuff tissue is reducible, arthroscopic m a n a g e m e n t s e e m s conceivable. The s h o r t - t e r m results of this p r o c e d u r e indicate that the device has m i n i m a l m o r -
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bidity b o t h at insertion a n d at follow-up, a n d leads to a successful surgical result in m o s t cases.
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