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Pearls and pitfalls of arthroscopicrotator-cuff repair
PEARLS AND PITFALLS OF ARTHROSCOPIC ROTATOR-CUFF REPAIR SAMER S. HASAN, MD, PhD and GARY M. GARTSMAN, MD
Arthroscopic rotator-cuff repair is rapidly gaining acceptance as an alternative to traditional open repair techniques. The surgeon who desires to make the transition to this technique needs to consider various factors, such as individual arthroscopic skills, surgical volume, and operating-room resources. The transition is a gradual and systematic one that requires patience, perseverance, and practice outside the operating room. Familiarity with the arthroscopic instruments and the basic steps needed to carry out the repair is essential. In this article, a framework for transition to arthroscopic repair and suggestions for avoiding common pitfalls are provided. KEY WORDS: rotator cuff, arthroscopy, repair, technique, complications
Copyright 2002, Elsevier Science (USA). All rights reserved.
RATIONALE BEHIND ARTHROSCOPIC CUFF REPAIR Arthroscopic rotator-cuff repair evolved gradually from traditional open repair techniques. Initially, the arthroscope was used to manage shoulder impingement and acromioclavicular joint arthritis. Surgeons gained useful information about the appearance of associated rotatorcuff lesions and began to repair the torn tendon to bone by using arthroscopic techniques. Pioneering work on arthroscopic repair techniques by Snyder, 1,2 Burkhart, 3,4, and Gazielly 5 have helped refine greatly this technique.
ADVANTAGES OF ARTHROSCOPIC CUFF REPAIR The advantages of arthroscopic rotator-cuff repair over traditional open and mini-open repair t e c h n i q u e s 6-12 a r e several. Arthroscopic repair preserves the deltoid attachment and prevents the potentially devastating complication of deltoid dehiscence that may occur after traditional open repair methods. Compared with the mini-open repair, arthroscopic repair may afford improved visualization of large to massive rotator-cuff tears. Because of the panoramic view provided by the arthroscope, the tear geometry and the extent of medial retraction can be visualized at once, instead of sequentially with internal and external rotation of the arm. The repair of rotator-cuff tears that extend medially or have retracted significantly is difficult using a mini-open technique. 11 This is because access to the tendon is impaired by the acromion and by limited exposure through a deltoid split that should not exceed 4 cm in length to preserve the axillary innervation to the
From the Cincinnati Sports Medicine and Orthopaedic Center, Cincinnati, OH, and the Texas Orthopedic Hospital, Houston, TX. Address reprint requests to Gary M. Gartsman, MD, Fondren Orthopadic Group, 7401 South Main, Houston, TX 77030-4509. Copyright 2002, Elsevier Science (USA). All rights reserved. 1048-6666/02/1203-0007535.00/0 doi:10.1053/otor.2002.36300
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anterior deltoid. 8 Additionally, some authors have noted an increased incidence of postsurgical stiffness after miniopen repair 13 that may relate to excessive deltoid traction in an attempt to improve visualization. In contrast to an open repair, arthroscopic repair avoids clinically relevant deltoid injury and requires less softtissue dissection. Postsurgical stiffness is uncommon, especially when passive motion is initiated immediately after repair. Consequently, patients generally experience less pain and rehabilitation is more rapid. Importantly, arthroscopy provides the ability to evaluate and treat concurrently glenohu_meral joint pathology. Arthroscopic repair techniques have specific advantages for patients who present with athletic injuries. These patients are often younger, more athletic, present for treatment more quickly, have smaller tendon tears, and are more likely to have coexisting intra-articular lesions than patients with degenerative tears. The skin incisions are smaller, which affords an improved cosmetic result. Lastly, an all-arthroscopic rotator-cuff repair by a skilled arthroscopist is less time consuming than a mini-open repair; this may help to offset the cost incurred by the use of specialized instruments and implantable anchors.
LIMITATIONS OF ARTHROSCOPIC CUFF REPAIR The limitations of an all-arthroscopic repair are that it is more dependent on arthroscopic skills than mini-open repair. These are skills that must be honed long before an arthroscopic repair is attempted. An all-arthroscopic repair requires specialized instruments such as suture passers and knot pushers and implantable devices such as suture anchors. These instruments must be mastered, too, and their use increases the cost of the repair, which must be considered as well. Lastly, some data have shown that arthroscopic suture-repair techniques may be inferior to recommended open techniques, although numerous studies have documented excellent clinical results with allarthroscopic repair at short- and intermediate-term follow-up.14-18 Operative Techniques in Orthopaedics, Vol 12, No 3, 2002: pp 176-185
INDICATIONS F"OR ARTHROSCOPIC CUFF REPAIR
PRACTICE IN PREPARATION FOR ARTHROSCOPIC CUFF REPAIR
The indications for an arthroscopic rotator-cuff repair are the same as those of an open or mini-open repair, t h e surgeon should not in any way alter or "broaden" these indications in the mistaken view that arthroscopic repair is a lesser procedure. Any patient unable to tolerate an open rotator-cuff repair or the rehabilitation that follows is not a candidate for an arthroscopic repair. Any tear that is amenable to treatment with open techniques is a candidate for arthroscopic treatment. This includes partial-thickness tears, small, medium, and large tears, and massive tears. Occasionally, rotator-cuff tears are irreparable, or not worth repairing, due to poor-quality tendon, advanced muscular atrophy, or static superior subluxation of the humeral head. ~9 These tears may be appropriate for debridement or for partial repairs by using either open or arthroscopic methods. Although all rotator-cuff tears can be treated arthroscopically, we do not suggest that the orthopedic surgeon commit to repair all rotator-cuff tears arthroscopically without adequate experience. Some tears are more amenable to arthroscopic repair than others. The following sections will help guide the surgeon through some of the necessary decision making.
The surgeon interested in making the transition to an all-arthroscopic technique should do so gradually and systematically. A mini-open cuff repair requires some of the same arthroscopic skills needed for arthroscopic rotator-cuff repair, including diagnostic evaluation of the glenohumeral joint, arthroscopic acromioplasty, and cuff mobilization.9,20,21 To begin the transition, it is essential to develop a ratiohal plan. Begin by approaching the open and mini-open repairs with the eye of an arthroscopist. Evaluate the shoulder arthroscopically before any repair. Evaluate tear geometry and measure the tear size and retraction with the arthroscope and arthroscopic instruments. Confirm your measurements during the open surgery. This intellectual first step--identifying tear size and geometry--is essential to arthroscopic rotator-cuff repair. Next, the steps of an arthroscopic repair need to be mastered individually outside of the operating room. These steps include: 1. anchor insertion, including familiarization with the various drills and guides that may be used; 2. suture management; 3. passing suture through tendon; and 4. arthroscopic knot tying. Various methods can be used to obtain the skills necessary to perform an arthroscopic rotator-cuff repair. A knot-tying board is a useful starting point to learn the basics of arthroscopic knot tying; these are available from various arthroscopic equipment vendors. Performing repairs on cadaveric shoulders in a wet laboratory setting may provide an additional opportunity to simulate the repair. However, it is important to note that specimens often have massive retracted rotatorcuff tears that make repair exceedingly difficult. The Alex Shoulder Professor model (Sawbones, Pacific Research Laboratories, Vashon, WA) is a sophisticated, commercially available model of the shoulder that consists of a felt rotator cuff and plastic glenohumeral joint, encased in a sturdy plastic shell that mimics shoulder surface anatomy. The lateral portion of the shell is clear and removable. It is an invaluable tool for learning some of the more subtle aspects of the repair. The model can be used in various ways. The clear plastic cover can be removed early in the learning process and then replaced to allow the surgeon to use portals during the repair. An arthroscope and monitor can be used to create a dry laboratory simulation. Finally, the clear cover can be replaced with an opaque one so that arthroscopic visualization is necessary. Although arthroscopic techniques are being taught at some residency programs and at many shoulder and sportsmedicine fellowships, most practicing orthopaedic surgeons have had little formal training. Current options for practicing orthopaedic sur g cons include instructional courses organized by the American Academy of Orthopaedic Surgeons, a n d by various specialty societies, as well as courses organized by various mstit~tions and vendors. We favor highly specialized hands-on courses that involve at the very least ~ e use of the arthroscopic instruments needed during repair. Some courses lack the hands-on component that allows the surgeon an opportunity to try various techniques, a n d t o repeat: various steps, to make mistakes, and to learn from ~ e m . Other courses
WHO SHOULD PERFORM AN ARTHROSCOPIC REPAIR? Attempting an arthroscopic rotator-cuff repair without adequate experience may be the initial pitfall. Indeed, it is relevant to ask the question: "Who should be considering arthroscopic rotator-cuff repairs?" Arthroscoplc rotatorcuff repair is technically demanding and subject to many potentially frustrating pitfalls, as we shall explore. There is no comparable, commonly performed all-arthroscopic procedure that is performed in other joints. The transition from a traditional mini-open technique to an all-arthroscopic technique has been reported to take from several morLths to over a year. To justify this commitment, the volume of rotator-cuff repairs needs to be high enough--at least 20 to 30 rotator-cuff repairs annually according to the senior author. Consequently, the technique should probably be reserved for surgeons with busy shoulder practices. The nature of the transition also dictates that this technique be reserved for those surgeons willing and able to deal with a slow, frustrating, and unpredictable transition. Because an atl-arthroscopic rotator-cuff repair technique is technically demanding some basic arthroscopic skills are required. The surgeon who undertakes an arthroscopic repair must be able to inspect the glenohumeral joint and perform subacromial decompression efficiently so that ampIe time is available to properly perform all the steps that constitute a repair. Although a formal arthroscopic acromioplasty is not essential to an arthroscopic rotatorcuff repair, the surgeon should be able to perform a diagnostic arthroscopy and arthroscopic bursectomy and acromioplasty in 30 minutes or less before an arthroscopic repair should be contemplated. PEARLS AND PITFALLS OF ARTHROSCOPIC ROTATOR-CUFF REPAIR
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are too broad in scope so that an inadequate time is allotted for arthroscopic rotator-cuff repair. Additional practice occurs during a transition to in vivo arthroscopic rotator-cuff repair. Initially, the arthroscope is used solely to measure the tear, and an open repair is performed after this. Next, the footprint of the rotator cuff or bony bed is decorticated by using an arthroscopic bur, and the anchors are inserted under arthroscopic guidance; the remaining steps are performed by using a mini-open technique. Subsequent steps involve passing the suture through the rotator-cuff tear edge, and then tying the sutures arthroscopically. At the end of each phase of the transition, the mini-open approach is used to verify the quality of the repair, as well as the overall placement of the anchors and the quality of the knots. The surgeon must not forget that transition is a process. In addition, a perfect rotator-cuff repair is the goal so that one should not hesitate to perform an open repair that may help attain that goal.
anesthesia supplemented with generally anesthesia is used. Regional anesthesia allows for a decreased use of anesthetic agents, which minimizes postoperative side effects and allows for excellent immediate postoperative pain relief. General anesthesia eliminates patient discomfort on the operating table as well as patient movement during the procedure. The anesthesiologist should be experienced in both and should be comfortable with patient positioning. Additionally, the anesthesiologist should be willing to provide hypotensive anesthesia with a target systolic blood pressure of 90 m m H g whenever possible. For surgeons using the lateral decubitus position, turning the table 180 ° so that the anesthesiologist is at the patient's feet greatly enhances the space available for the operating team to carry out the repair. It is invaluable to prepare the team for an arthroscopic repair by performing an in-service on the technique and on surgeon preferences.
PERFORMING ARTHROSCOPIC CUFF REPAIR
PATIENT POSITIONING
SELECTING THE FIRST TEAR FOR ARTHROSCOPIC CUFF REPAIR Once the surgeon is comfortable with the steps of an arthroscopic rotator-cuff repair and is ready to attempt its use in practice, it is important to begin selecting tears that may be appropriate for the initial arthroscopic repair. Small tears are obviously easier to repair than larger tears, which may require the use of several anchors and sutures. In addition, tears that are not significantly retracted are easier because less mobilization is required. Finally, a partial-thickness tear is a poor initial candidate for arthroscopic repair because establishing whether or not a repair is necessary requires an assessment of tear size and tear depth that may be difficult to perform arthroscopically. Additionally, the exact location of the tear is often difficult to identify, even after tagging the site with a suture, because the tear may involve only the articular surface and may not extend to the bursal surface.
ASSEMBLING YOUR TEAM
Surgical Assistance An experienced surgeon without an experienced team will encounter great hardship during the transition to an arthroscopic rotator-cuff repair. Although examples certainly exist of surgeons performing repairs without an assistant, the procedure is greatly facilitated by a competent first assistant who is trained specifically in all aspects of his technique as well as by a scrub nurse or tech that is familiar with the equipment used. Conducting an "Inservice" before using new equipment helps explain proper usage and underlying rationale to the operating room staff. The senior author performs all his arthroscopic rotator-cuff repairs jointly with the same assistant.
ANESTHESIA In addition to a well-trained orthopaedic team, a competent anesthesiologist is also essential. Interscalene block
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The decision on whether to use sitting (beach chair) or lateral decubitus position is one that the individual surgeon needs to make. The senior author uses the sitting position for both rotator-cuff and glenohumeral repairs but other surgeons prefer the lateral decubitus position. Proponents of the lateral decubitus position point to the ease of positioning the arm with a traction device and to advantages with glenohumeral visualization, especially posteriorly. Proponents of the beach-chair position point to the fact that the subacromial space can be positioned so that it is parallel to the floor, which may facilitate the repair as well as the ease of conversion to an open approach if necessary. However, because the mini-open approach can be performed in both positions, the surgeon should focus on mastering the steps to an arthroscopic repair and not try to alter positioning. Regardless of whether the decubitus or beach-chair position is preferred, patient positioning is critical to the success of the procedure. In the beach-chair position, the patient's torso should be flexed forward so that the acromion is as horizontal as possible. Posterior acromial slope varies from patient to patient and failure to position the patient so that the acromion (and subacromial space) is parallel to the floor results in the surgeon directing the arthroscope more vertically and having to work "uphill." Additionally, the field should be generously draped posteriorly, both for portal placement and for instrument manipulation. The use of the Schloein positioner (Orthopedic Systems, Union City, CA) greatly facilitates patient positioning for the senior author. The device allows the patient to sit upright and affords sufficient access to the posterior shoulder without requiring that the patient be translated laterally to the edge of the operating table. The patient's arm is controlled with a McConnell arm holder (McConnell Orthopedics, Greenville, TX) without occupying the assistant. The holder is invaluable in maintaining proper arm rotation so that the repair site is directly underneath the operating cannula. Rotating the table 45 ° with respect to the room also increases the space available for both the surgeon and assistant. HASAN AND GARTSMAN
ARTHROSCOPIC PORTALS
An arthroscopic rotator-cuff repair can be performed by using 3 portals: posterior, anterior, and lateral. Although these portals are used routinely during arthroscopic subacromial decompression, they must be positioned with greater precision to enable rotator-cuff repair. The senior author places the posterior portal nearer to the posterolateral corner of the acromion than traditional placement in the soft spot, typically 1 cm medially and 1-1.5 cm inferiorly. This ensures that the arthroscope can be inserted superiorly within the subacromial space to maxirnize the distance from the arthroscope to the rotator cuff, This creates "a room with a view" that allows for careful inspection of the rotator cuff and facilitates visualizatkm during the repair. STEPS OF AN ARTHROSCOPIC CUFF REPAIR
An arthroscopic rotator-cuff repair proceeds systematically in a logical step-wise fashion. The essential steps to a repair include visualization and decompression, inspection, abrasion of the foot print, anchor insertion, suture passage through tendon, and arthroscopic knot tying. Failure to perform adequately any of these steps will lead to failure of the repair. The details of an arthroscopic rotatorcuff repair have been described in previous articles by the senior author!°, a2-24 and by others. 2,4 In the sections that fol!ow, we wi!l describe some common pitfalls and share some pearls that may be worth remembering. DIAGNOSTIC ARTHROSCOPY
A careful yet efficient diagnostic arthroscopy should precede every rotator-cuff repair. The arthroscope is placed posteriorly and directed into the glenohumeral joint. The labrum, biceps, subscapularis, rotator interval, and both glenoid and humeral head articular surfaces should be inspected carefully' A probe inserted through an anterior cannula often helps here. The rotator-cuff footprint should be respected to confirm a full-thickness tear or to evaluate any partial tearing. The arthroscope can also be placed anteriorly to evaluate the posterior rotator cuff and la-bruin. Lesions that are identified are treated accordingly, including repair of labral tears and debridement. However, modest debridement of the various structures is not performed because it contributes little if anything to the patient,s condition In addition, time wasted unnecessarily o n debridement m a y limit the time available to carry out the repair if fluid extravasation and swelling occur. When a smal ! rotator,cuff tear is identified, placement of a suture marker may be helpful, although this is not performed r o u ~ e l y by the serdor author. This can be performed by using a 0-PDS passed through an 18-gauge spinal needle inserted from lateral or anterolateral into the site of the tear iCapsular releases may be performed on the articular side as needed during the glenohumeral arthroscopy. SUBACROMIAL DECOMPRESSION
Subacromial decompression is performed in routine fashion. 25-28 The arthrosc~pe is inserted through the posterior PEARLSAND PITFALLS;OF ARTHROSCOPICROTATOR-CUFFREPAIR
portal and directed toward the anterior acromion. Gentle medial to lateral sweeps performed with the sheath may enhance visualization. A lateral portal is established 2 cm distal and 2 cm posterior to the anterolateral corner of the acromion. Once the portal is established, a bursectomy is performed by using both a shaver and electrocautery, which allows for careful visualization of the bursal surface of the rotator-cuff tear. The reparability of the tear is determined before an acromioplasty is performed. 29 A tissue grasper is used to pull on the tear edge so as to determine the repair-site location. Varying both the direction of the pull and the degree of arm elevation and rotation is often required. 23 Typically the arm is positioned in 20 ° of elevation, 15 ° of abduction, and 10° of internal rotation. The arm is maintained in this position with the McConnell arm holder. Once reparability has been determined, the coracoacromial ligament is released and resected and an acromioplasty is performed by using a standard cutting-block technique. 2s The goal of the acromioplasty is to increase the volume of the subacromial space by converting a type 2 or 3 acromion to a flat, type 1 acromion. The inferior lateral acromion is thinned further if a lateral slope is identified on a magnetic resonance imaging scan or plain radiographs. An aggressive acromioplasty is not essential for an arthroscopic rotator-cuff repair and there is no need to perform an acromioplasty of a type I acromion. Indeed, the acromioplasty can be omitted altogether, thereby preserving the coracoacromial ligament, in situations whether the tendon tissue is of questionable quality and the healing of the repaired tendon is less predictable. Alternatively, electrocautery can be used to release, rather than resect, the ligament off the undersurface of the acromion. Proper placement of the arthroscopic portals and deft manipulation of the arthroscope are more important than an aggressive acromioplasty to create the "room with a v'lew" that facilitates arthroscopic rotator-cuff repair. TEAR VISUALIZATION
Once adequate bursa has been resected to allow visualization of the rotator-cuff tear, its morphology must be characterized in detail. This can be accomplished frequently with the arthroscope located posteriorly, but the surgeon should not hesitate to inspect the tear from the lateral portal to obtain the so-called "50-yard line view." With small to medium tears less than 3 cm in length, the size and tear geometry is often easily appreciated. Tear size is measured by comparing it to the known diameter of the lateral carmula. The length of the tear from anterior to posterior as well as the amount of medial retraction is noted. Straight medial retraction producing an elliptical defect is most common_ As tear size increases, the ability to appreciate tear geometry becomes more difficult. Reverse "L" tears with a longitudinal component along the rotator interval allow the tear to rotate posteriorly. "L"shaped tears have a longitudinal limb posteriorly, often at the junction of the supraspinatus and infraspinatus, in addition to lateral d e t a ~ e n t from the greater tuberositv. Longitudinal tears may occur in the area of the rotator interval and occasionally within the supraspinatus tendon. 1 '79
Only when tear geometry is appreciated can an effective repair be performed.
ROTATOR-CUFF MOBILIZATION Mobilizing a retracted rotator-cuff tear is a critical step in the repair. Adhesions often form with the subacromial space between rotator cuff and acromion or deltoid, interfering with tendon mobilization and frequently giving a false impression of irreparability. Dense adhesions between the anterior margin of the tear and coracoid often form, especially around the coracohumeral ligament, and these require release with electrocautery. A power shaver is not used so as to prevent bleeding that is often difficult to control, owing to the medial location of the bleeding vessels. Posterior adhesions usually are not as dense and can often be released b y inserting a metal trocar and cannula through the lateral portal, placing it superior to the anterior tear edge and sweeping posteriorly directly beneath the acromion. Electrocautery can also be used if the adhesions are especially thick. Adhesions may also form on the articular surface of the tendon between cuff and superior glenohumeral joint capsule and labrum that require intra-articular release.
SIDE-TO-SIDE REPAIR AND MARGIN CONVERGENCE Once tear geometry has been established, the repair must be visualized exactly as it will be performed. Specifically, the precise location of the anchors and various stitches and the exact sequence of repair steps should be thought out before undertaking the repair. For large tears with an L or reverse-L shape the longitudinal split is first repaired in side-to-side fashion from medial to lateral, and then the transverse distal portion is repaired to bone with suture anchors. If the tear has a U-shaped configuration, such as the degenerative tear that is retracted, then the tear size should be diminished by first repairing the medial aspect with a side-to-side technique and then repairing the remaining tear to bone with suture anchors. This technique is referred to as margin convergence and was popularized by Burkhart. 3 The advantages of this technique are that it decreases the forces acting at the repair site and helps "converge" the tear toward its footprint, thereby decreasing the tendon tear size.
decorticates the bone to a depth of 1-2 mm and a width of roughly 1 cm in order to create a cancellous bed for the tendon (Fig 1). 23 A deeper trough, commonly performed during open repair, has not been found to be necessary. A deep trough may also lead to loss of effective rotator-cuff length and increase the tension across the repair. Tendon tear length determines the anterior-to-posterior dimension of the repair site.
REPAIR STRATEGIES AND USE OF SPECIALIZED INSTRUMENTS Once the locations of the various sutures are visualized the next step is to decide which techniques will be used to pass the sutures through tendon. In general there are 2 basic types of techniques: direct or shuttle. Direct techniques use instruments that directly pass the suture through the tendon. Examples of these instruments are the Cuff Stitch and Arthropierce (Smith-Nephew Endoscopy, Andover, MA), Viper (Arthrex, Naples, FL) and Penetrator (Arthrex), and Blitz (Linvatec, Largo, FL). Shuttle techniques use instruments that first pass a suture or wire shuttle through tendon. The shuttle then is used to pass the actual suture through tendon. Instruments used to shuttle wire or suture include the Caspari punch (Linvatec) and the Spectrum Suture Needles (Linvatec). The Spectrum device can also be used to pass s u c r e directly, such as for a side to side repair with monofilament suture. Determining whether to use a direct or shuttle technique depends on the geometry or the tear as well as on the prepared working portal. In general if the lateral portal is the working portal then a direct technique works best for the side to side repair such as during margin convergence. In contrast the shuttle technique is best suited for repairing the tendon directly to bone. Both techniques require a meticulous attention to detail. Side-to-side repairs are performed by using permanent braided or monofflament sutures or slowly absorbable monofilament suture such as O-polydioxanone suture (OPDS). Typically, a suture passer is inserted through the anterior portal while viewing through the lateral portal; the suture is passed in simple fashion across the split. Anterior tears, such as those with a rotator interval split,
PREPARING THE ROTATOR CUFF Before suture repair, the tendon edges should be gently debrided to remove devitalized tissue and promote healing. The debridement should aim to refresh the tendon edge rather than to remove it, so as not to jeopardize the repair. Debriding 1 or 2 millimeters of tendon edge is all that is necessary. More extensive debridement may shorten the tendon and result in a nonanatomic repair or one that is under excessive tension.
PREPARING THE REPAIR SITE The repair site must be prepared at the rotator-cuff footprint just lateral to the articular margin before initiating tendon-to-bone repair. A 4-mm arthroscopic round bur
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Fig 1. Decortication of the rotator-cuff footprint.
HASANANDGARTSMAN
I(
%
Fig 3. Arthroscopic view of lateral suture anchor placement.
9,
Fig 2. Lateral placement of suture anchor ("deadman's angle").
require a coiled or sharply angled suture passer or retriever. Both suture ends are retrieved out the posterior portal so that arthroscopic techniques can be used to tie the knot. A sliding ];not such as the Duncan loop, followed by 3 half hitches, is typically used to tie monofilament suture. 30 ANCHOR
INSERTION
The number of anchors depends on the length of the rotator-cuff tear. For all but the smallest tears, 2 suture anchors are used; massive (>5 cm) tears may require 3 or 4 anchors. Currently available suture anchors are loaded with either 1 or 2 sutures. Those with 2 sutures are preferred because they disperse loads more efficiently, but these require additional suture-management skills. In addition, #2 nonabsorbable suture is preferred, although some surgeons use slowly absorbable braided suture such as Panacryl TM. The use of different-colored sutures aids in suture identification and management. Although some surgeons elect to place the anchors into the rotator-cuff footprint there are a number of reasons for more lateral placement of the anchors. Burkhart has written about the mechanical advantage of inserting anchors so that they are directed 45 ° inferomedially, or at a "deadman's" angle. 31 This orientation places the line of pull 90 ° to the direction of the anchor, which minimizes anchor pullout (Fig 2). Lateral anchor position permits an anatomic repair because the tendon is pulled laterally toward the tendon bed. The anchor is placed in bone with an intact PEARLS AND PITFALLS OF ARTHROSCOPIC ROTATOR-CUFF REPAIR
cortical surface instead of the prepared cancellous bed at the repair site. Lateral anchor placement also enables the sutures to be tied laterally; this may limit suture impingement, a frequent postoperative nuisance. Avoiding the footprint increases the area available for tendon to bone healing. An 18-gauge spinal needle can be inserted through the lateral portal to determine the appropriate angle for anchor insertion (Fig 3). Some anchors require predril!ing and others do not; some anchors are pushed into place and others are screwed into place manually. To minimize the potential for anchor migration32 it is important to verify adequate anchor purchase and proper insertion. This is accomplished by tugging firmly on the sutures once the anchor has been inserted while viewing the insertion site arthroscopically. Most anchors have oblong eyelets so that the final ori~ entation of the anchors is important. In general, anchors should be inserted such that the eyelet is parallel to the tendon edge instead of facing the edge. Most anchors are inserted with devices that clearly mark the location of the eyelet to facilitate proper orientation (Fig 4). This is to
Fig 4. Arthroscopic view of metallic suture anchor attached to insertion device. The vertical mark on the inserter identi, ties the orientation of the eyelet. 1 81
Typically, all the suture anchors are inserted and the suture limbs retrieved before passing the sutures through the free tendon edge. Suture anchors are always inserted in the same sequence from anterior to posterior so that those anchors already in bone do not impair visualization as subsequent anchors are inserted. This order also minimizes the likelihood of suture entanglement because the sutures that are retrieved from the first anchor through the anterior portal remain anterior to any subsequent anchor.
SUTURE PLACEMENT
Fig 5. Close-up of suture anchor eyelet. The suture makes a 90 ° turn with respect to eyelet, which minimizes suture abrasion.
prevent one suture limb from taking an 180 ° turn as the suture is tied. This is especially true when using metallic anchors, especially those with sharp edged eyelets that may abrade the suture. This may be less important for bioabsorbable anchors, whose eyelets are round and blunt or made of suture. If the anchor used requires predrilling, make sure that no suture limbs are within the subacromial space before drilling or they will become entangled. In addition, if the anchor is inserted so that the eyelet is parallel to the tendon edge, then either suture limb can be passed through tendon. If the eyelet is perpendicular, then there is a 50% chance that the limb selected for passage will make a 180 ° turn as it exits the eyelet, leading to potential abrasion of the suture (Fig 5).
Once the anchors are inserted and their sutures retrieved, the sutures are passed through tendon. The soft-tissue grasper is passed through the lateral cannula, and the precise location for the tendon repair as well as the location and spacing of each suture is estimated. We space the sutures evenly from anterior to posterior margin. The sutures are passed through tendon from anterior to posterior. Although various techniques exist for passing suture through tendon, a rather straightforward technique uses a Caspari suture punch to pass a suture relay that then is used to pass the suture from the anchor across the tendon. The Caspari suture punch cannot be used to pass the suture directly because it will not accept a #2 braided suture. The device is loaded with a 2-0 nylon suture that is folded in half so that the 2 free ends are just beneath the needle tip and the looped end exits from the handle. The device is inserted through the lateral portal and aimed at the portion of tear corresponding to the anchor. The device grasps and punctures the tendon 5 mm medial to the tendon edge, until the needle is visible on the bursal surface (Fig 6). When using a suture anchor loaded with 2 sutures the surgeon should know the order in which the sutures are loaded. The order is important when the geometry of the eyelet forces the sutures to be stacked. In this
SUTURE PLACEMENT, SUTURE PASSAGE, AND KNOT TYING Suture Retrieval After each suture anchor has been inserted, the sutures are retrieved by using a crochet hook or similar device. The crochet hook is usually inserted through the anterior portal. However, when performing repairs of large rotatorcuff tears requiring 2 or more anchors, the sutures may be retrieved percutaneously from an anterolateral stab incision, which helps considerably with suture management.
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Fig 6. Close-up of suture anchor eyelet showing stacked arrangement of the 2 #2 nonabsorbable sutures.
HASANANDGARTSMAN
Fig 8. The 2 free ends of #2-0 nylon suture are withdrawn through the anterior cannula by using a crochet hook or similar device.
Fig 7o Caspari suture punch through the edge of the rotator= cuff tendon. Two free ends of #2-0 nylon suture protrude just past the tip of the needle, A crochet hook has been inserted through the anterior portal to push down on the tendon and facilitlate puncture of the tendon.
case, the top suture is passed first so that it may be tied first "without binding the bottom suture (Fig 6). The Caspari suture punch was originally intended to pass a braided wire shuttle across the tendon. However, a 2-0 nylon suture shuttle is far less expensive and the wire shuttle may cause tissue abrasion. Dr. Snyder has modified the Caspari suture punch so that the end of the punch is slotted. This greatly facilitates removal of the punch once the suture shuttle has been passed. To puncture the thicker tendons often seen in younger adults, the senior author has lengthened the needle at the tip of the suture punch. These modifications are available commercially. Pushing on the tendon near the Caspari suture punch by using the crochet hook inserted anteriorly facilitates passage of the device through tendon (Fig 7). This provides the countertraction that is often needed when the tendon is thick.
punch is withdrawn, the looped end of the suture shuttle projects out the lateral cannula. Next, one of the anterior suture anchor strands is retrieved out the lateral cannula by using a crochet hook. When double-loaded anchors are used, 1 limb of the topmost suture is selected to be passed first. A hemostat clamps the remaining anterior suture anchor strand. Approximately 3 inches of the braided suture is placed within the loop of the 2-0 nylon suture external to the lateral cannula. If less than 3 inches of suture are passed through the loop then it may uncouple from the suture shuttle as the shuttle is passed through the tendon. Whenever a suture limb shares a cannula with a suture shuttle, it is critical to check that they are not entangled before the limb is coupled to the shuttle. A suture retrieval forcep is inserted through that cannula into the subacromial space and both strands of nylon suture are enclosed within the jaws of the suture-retrieval forceps. The jaws are kept closed around the 2 nylon suture strands as the retrieval forceps is removed from the cannula (Fig 9). This
COMPLETING THE RELAY
Once the free ends of the shuttle are delivered into the subaeromia! space, a crochet hook is used to retrieve both ends out the anterior portal (Fig 8). The assistant applies a hemostat to the suture ends so that they are not accidentally pulled back into the subacromial space. After the shuttle ends are retrieved, the jaws of the Caspari punch are opened as the device is withdrawn from the tendon and then :the lateral cannula. A gentle d o w n w a r d push on the Caspari suture punch facilitates its withdrawal from the tendon. Failure to do so may lacerate the shuttle suture ends against t h e needle tip, in which case the Caspari suture punch must be reloaded. Once the Caspari suture PEARLS AND PITFALLS OF ARTHROSCOPIC ROTATOR-CUFF REPAIR
Fig 9. The suture retrieval forceps ensure that sutures are not entangled. 183
step should be repeated for each braided suture in order to ensure that it is not entangled with the nylon shuttle. Traction is placed on the 2 free ends of the nylon suture anteriorly and the braided suture is pulled from the lateral carmula into the subacromial space, through the tendon, and out the anterior cannula. At this point, a simple suture has been placed through the rotator cuff (Fig 10). The 2 suture limbs from the anchor are clamped and ready to be tied. These steps are repeated as necessary. While viewing the repair from posterior, the knots should generally be tied from posterior to anterior, although the surgeon may modify this according to tear geometry. Each knot should be tied and suture limbs cut before proceeding to the next knot in order to minimize clutter in the subacromial space. Various suture techniques to place mattress (easily performed by using the suture shuttle to pass both suture strands) and MasonAllen stitches have been performed but they are cumbersome and time consuming. We prefer to use simple sutures to repair all sizes of rotator-cuff tears and have not experienced problems with suture pullout.
ARTHROSCOPIC KNOT TYING It is important to master at least i sliding and I nonsliding knot. In general, sliding knots are best suited for monofilament suture such as PDS and nonsliding knots are best for braided suture, which may not slide as well. Nottage and Lieurance have written an excellent review on arthroscopic knot tying, s° which includes detailed illustrated instructions for tying various sliding and nonsliding knots. The importance of truly mastering arthroscopic knot tying can not be overstated. An arthroscopic repair that has been carefully planned and executed will certainly fail if the sutures are not tied in such as manner that both loop security and knot security are achieved. Loop security is achieved by maintaining tight suture loops before knot tying, as whereas knot security is the effectiveness of a given knot at resisting slippage. 34 Arthroscopic knot tying should be practiced first on a knot-tying board with rope to learn the general concepts, and then practiced further with suture and instruments.
Arthroscopic knot tying uses instruments in place of the surgeon's fingers to deliver and secure the knot. These instruments include slotted or closed knot pushers, some of which can be used as pushers/pullers, as well as specialized instruments such as the 6th Finger (Arthrex, Naples, FL). The surgeon should try various instruments and determine which one works best.
ARTHROSCOPIC KNOT TYING: STEPS The first step in tying an arthroscopic knot is to deliver the suture limbs to the portal that will be used to tie the knots. With the arthroscope in the posterior portal, the suture limbs are delivered from the anterior cannula to the lateral cannula. A suture-retrieval forcep encloses i of the 2 limbs in the subacromial space and is removed from the lateral cannula while its jaws are closed to ensure that the limbs are not entangled. The next step is determining which suture limb is the post. The suture limb that has not been passed through tendon serves as the initial post so that the throws lie flat. The post limb is threaded through the knot pusher and the end of the limb is clamped with a hemostat. The knot is made and the knot pusher pushes the knot down the cannula to the tissue. It is important to visualize arthroscopically the knot as it descends to make sure that it lays flat. Gently rotating the knot pusher helps with this. Once the knot is flat, the pusher can be used as a "puller" by pass pointing on the suture limb to help cinch it. Harryman et al have shown that alternating the direction of the half hitches and alternating posts optimize the security of the repair. 35,36 Three half hitches are needed to secure a sliding knot or a nonsliding knot. Burkhart and Chan have described a technique for reversing the post without actually threading the other limb through the knot pusher. 37 To accomplish this, differential tension is applied on the 2 suture limbs, which causes the knot to "flip," resulting in a reversal of the post. This change in post can be directly viewed arthroscopically. This technique saves time by eliminating multiple manipulations of the knot pusher. Once the knots have been tied and secured with additional half hitches, the suture ends are cut by using any of several available arthroscopic scissors so that 3 to 4 mm ends remain.
KNOWING WHEN TO SAY WHEN It is useful to remain aware of the clock during an arthroscopic rotator-cuff repair. The surgeon should always be willing to convert to a mini-open repair after a certain time has elapsed or in situations when significant fluid extravasation has occurred.
POSTOPERATIVE
Fig 10, Arthroscopic view showing a completed simple pass of #2 nonabsorbable suture through the tendon,
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MANAGEMENT
Rehabilitation after arthroscopic rotator-cuff repair is essentially the same as that after open or mini-open repair. 23 Although the skin incisions are smaller and the deltoid attachment is preserved, all elements of an open repair are performed in an arthroscopic repair. Consequently, the repaired tendon or tendons need to be protected, typically for 4 - 6 weeks. HASAN AND GARTSMAN
Patients are admitted overnight for pain management. Initial emphasis is placed on recovering passive range of motion. Patients use a continuous passive-motion chair in the hospital and for 2 weeks at home to aid in recovery of passive motion. The machine moves the arm in elevation and then in external rotation through safe limits that are established at the time of surgery. Patients are cautioned not be begin active shoulder motion too early. This is a concern because many patients are off of narcotic analgesics in a matter of days or a couple of weeks and begin to feel "good" before the tendon has healed adequately. Patients begin active assisted range of motion 6 weeks after surgery, at which time they may slowly resume arm use during activities of daily living. Driving is generally allowed 2 weeks after surgery. Strengthening is instituted at 3 months and the rehabilitation continues for 12 months as needed. Patients often return to low-demand jobs within a week or 2 but return to unrestricted repetitive overhead work or sport may take 6 months or longer.
REFERENCES 1. Snyder SJ, Foos GR: Arthroscopic treatment of bursal side and full thickness rotator cuff tears. Ann Chir Gynaecol 85:117-125, 1996 2. Snyde r SJ: Technique of arthroscopic rotator cuff repair using implantable 4-ram Revo sutazre anchors, suture Shuttle Relays, and no. 2 nonabsorbable mattress sutures. Orthop Clin North Am 28:267-275, 1997 3. Burkhart SS, Athanasiou KA, Wirth MA: Margin convergence: A method of reducing strain in massive rotator cuff tears. Arthroscopy !2:335-338, 1996 4. Burkhart SS: A stepwise approach to arthroscopic rotator cuff repair based on biomechanicat principles. Arthroscopy 16:82-90, 2000 5. Gazielly DF, Gleyze P, Montagnon C, etal: Arthroscopic repair of distal supraspinatus tears with Revo Screw and permanent mattress sutures: A preliminary report. Presented at the American Shoulder and Elbow Surgeons 13th Annual Meeting, Amelia Island, FL, 1996 6. Paulos LE, Kody MH: Arthroscopically enhanced "miniapproach" to rotator cuff repair; Am J Sports Med 22:19-25, 1994 7. Blevins FT, Warren RF, Cavo C, et al: Arthroscopic assisted rotator cuff repair: Results using a mini-open deltoid splitting approach. Arthrescopy 12:50-59, 1996 8. Bachner EJ, Snyder SJ: Arthroscopic subaeromial decompression, arthroscopic-assisted (mini-open) rotator cuff repair, and arthroscopic cuff repair, in Burkhead WZ Jr (ed). Rotator Cuff DisorderS. Baltimore, Williams & Wilkins, 1996, pp 271-289 9, Gartsman GM I C0rabined arthroscopic and open treatment of tears of the rotator cuff ~J Bone Joint Surg 79A:776-783, 1997 10. Gartsman GMi Hammerman SM: Full-thickness tear: Arthroscopic repairl Orth Clin North Am 28:83-98, 1997 11. Warner JJ, Goit~ I~l, Irrgang JJ, et al: Arthroscopic-assisted rotator cuff repair: Patient selection and treatment outcome. J Shoulder Elbow Surg 6:463±472, 1997 12. Gartsman GM: Arthroscopic management of rotator cuff disease. J Am Acad Orthop Surg 6:259-266, 1998
PEARLS AND PITFALLS OF ARTHROSCOPIC ROTATOR-CUFF REPAIR
13. Norberg FB. Field LD, Savoie FH III: Repair of the rotator cuff. Mini-open and arthroscople repairs. Clin Sports Med 19:77-99, 2000 14. Murray TF Jr, Lajtai G, Mileski RM, et ah Arthroscopic repair of medium to large full-thickness rotator cuff tears: Outcome at 2- to 6-year follow-up. J Shoulder Elbow Surg 11:19-24. 2002 15. Gartsman GM. Brinker MR, Khan M: Earlv effectiveness of arthroscopic repair for full-thickness tears of the rotator cuff - an outcome analvsis. J Bone Joint Surg 80A:33-40, 1998 16. Gartsman GM, Khan M, Harnmerman SM: Arthroscopic repair of full-thickness rotator cuff tears. J Bone Joint Surg 80A:832-840, 1998 17. Stollsteimer GT, Savoie FH III: Arthroscopic rotator cuff repair: Current indications, limitations, techniques, and results. Instr Course Lect 47:59-65, 1998 18. Tauro JC: Arthroscopic rotator cuff repair: Analysis of technique and results at 2- and 3-year follow-up. Arthroscopy 14:45-51, 1998 19. Gerber C, Fuchs B, Hodler J: The results of repair of massive tears of the rotator cuff. J Bone Joint Surg 82A:505-515, 2000 20. Yamaguchi K: Mini-open rotator cuff repair: An updated perspective. Instr Course Lect 50:53-61, 2001 21. Yamaguchi K, Ball CM, Galatz LM: Arthroscopic rotator cuff repair: Transition from mini-open to alI-arthroscopic. Clin Orthop 390:83-94, 2001 22. Gartsman GM, Hammerman SM: Arthroscopic repair of full-thickness rotator cuff tears: Operative technique. Op Tech Orth 8:226-235. 1998 23. Gartsman GM, Hammerman, SM: Arthroscopic repair of full-thickness rotator cuff tears. Op Tech Shoulder Elbow Surg 1:2-8, 1999 24. Gartsman GM: Arthroscopic rotator cuff repair. Clin Orthop 390:9510G 2001 25. Ellman H: Arthrscopic subacromial decompression: Analysis of one to three year results. Arthroscopy 3:173-t81, 1987 26. Ellman H, Kay SP: ArthroscopK subacromial decompression for chronic impingement. Two- to five year results. J Bone Joint Surg Br 73:395-398, 1991 27. Gartsman GM, Blair ME, Noble PC, et al: Arthroscopic subacromial decompression. An anatomical study. Am J Sports Med 16:48-50, 1988 28. Gartsman GM: Arthroscopic acromioplasty for lesions of the rotator cuff. I Bone Joint Surg 72A:169-180, 1990 29. Gartsman GM: Arthroscoplc assessment of rotator cuff reparability. Arthroscopy 12:546-549, 1996 30. Nottage WM, Lieurance RK: Arthroscopic knot tying techniques. Arthroscopy 15:515-521, 1999 31. Burkhart SS: The deadman theory of suture anchors: Observations along a south Texas fence line. Arthroscopy 11:119-123, 1995 32. Weber SC, Abrams JS, Nottage WM: Complications associated with arthroscopic shoulder surgery. Arthroscopy 18(suppl):88-95, 2002 33. Burkhart SS, Wirth MA, Simonich M, et al: Loop security as a determinant of tissue fixation security. Arthroscopy 14:773-776, 1998 34. Burkhart SS, Wirth MA, Simonich M, et al: Knot security in simple sliding knots and its relationship to rotator cuff repair: How secure must the knot be? Arthroscopy 16:202-207, 2000 35. Loutzenheiser TD, Harryman DT 1I, Yung SW, et al: Opthnizing arthroscopic knots. Arthroscopy 11:199-206. 1995 36. Loutzenheiser TD, Harryman DT I1, Ziegter DW, et al: Optimizing arthroscopic knots using braided or monofilament suture. Arthroscopy 14:57-65, 1998 37. Chan KC, Burkhart SS: How to switch posts without rethreading when tying half-hitches. Arthroscopy 15:444-450, 1999
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Arthroscopic rotator-cuff repair is rapidly gaining acceptance as an alternative to traditional open repair techniques. The surgeon who desires to make the transition to this technique needs to consider various factors, such as individual arthroscopic skills, surgical volume, and operating-room resources. The transition is a gradual and systematic one that requires patience, perseverance, and practice outside the operating room. Familiarity with the arthroscopic instruments and the basic steps needed to carry out the repair is essential. In this article, a framework for transition to arthroscopic repair and suggestions for avoiding common pitfalls are provided. KEY WORDS: rotator cuff, arthroscopy, repair, technique, complications
Copyright 2002, Elsevier Science (USA). All rights reserved.
RATIONALE BEHIND ARTHROSCOPIC CUFF REPAIR Arthroscopic rotator-cuff repair evolved gradually from traditional open repair techniques. Initially, the arthroscope was used to manage shoulder impingement and acromioclavicular joint arthritis. Surgeons gained useful information about the appearance of associated rotatorcuff lesions and began to repair the torn tendon to bone by using arthroscopic techniques. Pioneering work on arthroscopic repair techniques by Snyder, 1,2 Burkhart, 3,4, and Gazielly 5 have helped refine greatly this technique.
ADVANTAGES OF ARTHROSCOPIC CUFF REPAIR The advantages of arthroscopic rotator-cuff repair over traditional open and mini-open repair t e c h n i q u e s 6-12 a r e several. Arthroscopic repair preserves the deltoid attachment and prevents the potentially devastating complication of deltoid dehiscence that may occur after traditional open repair methods. Compared with the mini-open repair, arthroscopic repair may afford improved visualization of large to massive rotator-cuff tears. Because of the panoramic view provided by the arthroscope, the tear geometry and the extent of medial retraction can be visualized at once, instead of sequentially with internal and external rotation of the arm. The repair of rotator-cuff tears that extend medially or have retracted significantly is difficult using a mini-open technique. 11 This is because access to the tendon is impaired by the acromion and by limited exposure through a deltoid split that should not exceed 4 cm in length to preserve the axillary innervation to the
From the Cincinnati Sports Medicine and Orthopaedic Center, Cincinnati, OH, and the Texas Orthopedic Hospital, Houston, TX. Address reprint requests to Gary M. Gartsman, MD, Fondren Orthopadic Group, 7401 South Main, Houston, TX 77030-4509. Copyright 2002, Elsevier Science (USA). All rights reserved. 1048-6666/02/1203-0007535.00/0 doi:10.1053/otor.2002.36300
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anterior deltoid. 8 Additionally, some authors have noted an increased incidence of postsurgical stiffness after miniopen repair 13 that may relate to excessive deltoid traction in an attempt to improve visualization. In contrast to an open repair, arthroscopic repair avoids clinically relevant deltoid injury and requires less softtissue dissection. Postsurgical stiffness is uncommon, especially when passive motion is initiated immediately after repair. Consequently, patients generally experience less pain and rehabilitation is more rapid. Importantly, arthroscopy provides the ability to evaluate and treat concurrently glenohu_meral joint pathology. Arthroscopic repair techniques have specific advantages for patients who present with athletic injuries. These patients are often younger, more athletic, present for treatment more quickly, have smaller tendon tears, and are more likely to have coexisting intra-articular lesions than patients with degenerative tears. The skin incisions are smaller, which affords an improved cosmetic result. Lastly, an all-arthroscopic rotator-cuff repair by a skilled arthroscopist is less time consuming than a mini-open repair; this may help to offset the cost incurred by the use of specialized instruments and implantable anchors.
LIMITATIONS OF ARTHROSCOPIC CUFF REPAIR The limitations of an all-arthroscopic repair are that it is more dependent on arthroscopic skills than mini-open repair. These are skills that must be honed long before an arthroscopic repair is attempted. An all-arthroscopic repair requires specialized instruments such as suture passers and knot pushers and implantable devices such as suture anchors. These instruments must be mastered, too, and their use increases the cost of the repair, which must be considered as well. Lastly, some data have shown that arthroscopic suture-repair techniques may be inferior to recommended open techniques, although numerous studies have documented excellent clinical results with allarthroscopic repair at short- and intermediate-term follow-up.14-18 Operative Techniques in Orthopaedics, Vol 12, No 3, 2002: pp 176-185
INDICATIONS F"OR ARTHROSCOPIC CUFF REPAIR
PRACTICE IN PREPARATION FOR ARTHROSCOPIC CUFF REPAIR
The indications for an arthroscopic rotator-cuff repair are the same as those of an open or mini-open repair, t h e surgeon should not in any way alter or "broaden" these indications in the mistaken view that arthroscopic repair is a lesser procedure. Any patient unable to tolerate an open rotator-cuff repair or the rehabilitation that follows is not a candidate for an arthroscopic repair. Any tear that is amenable to treatment with open techniques is a candidate for arthroscopic treatment. This includes partial-thickness tears, small, medium, and large tears, and massive tears. Occasionally, rotator-cuff tears are irreparable, or not worth repairing, due to poor-quality tendon, advanced muscular atrophy, or static superior subluxation of the humeral head. ~9 These tears may be appropriate for debridement or for partial repairs by using either open or arthroscopic methods. Although all rotator-cuff tears can be treated arthroscopically, we do not suggest that the orthopedic surgeon commit to repair all rotator-cuff tears arthroscopically without adequate experience. Some tears are more amenable to arthroscopic repair than others. The following sections will help guide the surgeon through some of the necessary decision making.
The surgeon interested in making the transition to an all-arthroscopic technique should do so gradually and systematically. A mini-open cuff repair requires some of the same arthroscopic skills needed for arthroscopic rotator-cuff repair, including diagnostic evaluation of the glenohumeral joint, arthroscopic acromioplasty, and cuff mobilization.9,20,21 To begin the transition, it is essential to develop a ratiohal plan. Begin by approaching the open and mini-open repairs with the eye of an arthroscopist. Evaluate the shoulder arthroscopically before any repair. Evaluate tear geometry and measure the tear size and retraction with the arthroscope and arthroscopic instruments. Confirm your measurements during the open surgery. This intellectual first step--identifying tear size and geometry--is essential to arthroscopic rotator-cuff repair. Next, the steps of an arthroscopic repair need to be mastered individually outside of the operating room. These steps include: 1. anchor insertion, including familiarization with the various drills and guides that may be used; 2. suture management; 3. passing suture through tendon; and 4. arthroscopic knot tying. Various methods can be used to obtain the skills necessary to perform an arthroscopic rotator-cuff repair. A knot-tying board is a useful starting point to learn the basics of arthroscopic knot tying; these are available from various arthroscopic equipment vendors. Performing repairs on cadaveric shoulders in a wet laboratory setting may provide an additional opportunity to simulate the repair. However, it is important to note that specimens often have massive retracted rotatorcuff tears that make repair exceedingly difficult. The Alex Shoulder Professor model (Sawbones, Pacific Research Laboratories, Vashon, WA) is a sophisticated, commercially available model of the shoulder that consists of a felt rotator cuff and plastic glenohumeral joint, encased in a sturdy plastic shell that mimics shoulder surface anatomy. The lateral portion of the shell is clear and removable. It is an invaluable tool for learning some of the more subtle aspects of the repair. The model can be used in various ways. The clear plastic cover can be removed early in the learning process and then replaced to allow the surgeon to use portals during the repair. An arthroscope and monitor can be used to create a dry laboratory simulation. Finally, the clear cover can be replaced with an opaque one so that arthroscopic visualization is necessary. Although arthroscopic techniques are being taught at some residency programs and at many shoulder and sportsmedicine fellowships, most practicing orthopaedic surgeons have had little formal training. Current options for practicing orthopaedic sur g cons include instructional courses organized by the American Academy of Orthopaedic Surgeons, a n d by various specialty societies, as well as courses organized by various mstit~tions and vendors. We favor highly specialized hands-on courses that involve at the very least ~ e use of the arthroscopic instruments needed during repair. Some courses lack the hands-on component that allows the surgeon an opportunity to try various techniques, a n d t o repeat: various steps, to make mistakes, and to learn from ~ e m . Other courses
WHO SHOULD PERFORM AN ARTHROSCOPIC REPAIR? Attempting an arthroscopic rotator-cuff repair without adequate experience may be the initial pitfall. Indeed, it is relevant to ask the question: "Who should be considering arthroscopic rotator-cuff repairs?" Arthroscoplc rotatorcuff repair is technically demanding and subject to many potentially frustrating pitfalls, as we shall explore. There is no comparable, commonly performed all-arthroscopic procedure that is performed in other joints. The transition from a traditional mini-open technique to an all-arthroscopic technique has been reported to take from several morLths to over a year. To justify this commitment, the volume of rotator-cuff repairs needs to be high enough--at least 20 to 30 rotator-cuff repairs annually according to the senior author. Consequently, the technique should probably be reserved for surgeons with busy shoulder practices. The nature of the transition also dictates that this technique be reserved for those surgeons willing and able to deal with a slow, frustrating, and unpredictable transition. Because an atl-arthroscopic rotator-cuff repair technique is technically demanding some basic arthroscopic skills are required. The surgeon who undertakes an arthroscopic repair must be able to inspect the glenohumeral joint and perform subacromial decompression efficiently so that ampIe time is available to properly perform all the steps that constitute a repair. Although a formal arthroscopic acromioplasty is not essential to an arthroscopic rotatorcuff repair, the surgeon should be able to perform a diagnostic arthroscopy and arthroscopic bursectomy and acromioplasty in 30 minutes or less before an arthroscopic repair should be contemplated. PEARLS AND PITFALLS OF ARTHROSCOPIC ROTATOR-CUFF REPAIR
"! 7 7
are too broad in scope so that an inadequate time is allotted for arthroscopic rotator-cuff repair. Additional practice occurs during a transition to in vivo arthroscopic rotator-cuff repair. Initially, the arthroscope is used solely to measure the tear, and an open repair is performed after this. Next, the footprint of the rotator cuff or bony bed is decorticated by using an arthroscopic bur, and the anchors are inserted under arthroscopic guidance; the remaining steps are performed by using a mini-open technique. Subsequent steps involve passing the suture through the rotator-cuff tear edge, and then tying the sutures arthroscopically. At the end of each phase of the transition, the mini-open approach is used to verify the quality of the repair, as well as the overall placement of the anchors and the quality of the knots. The surgeon must not forget that transition is a process. In addition, a perfect rotator-cuff repair is the goal so that one should not hesitate to perform an open repair that may help attain that goal.
anesthesia supplemented with generally anesthesia is used. Regional anesthesia allows for a decreased use of anesthetic agents, which minimizes postoperative side effects and allows for excellent immediate postoperative pain relief. General anesthesia eliminates patient discomfort on the operating table as well as patient movement during the procedure. The anesthesiologist should be experienced in both and should be comfortable with patient positioning. Additionally, the anesthesiologist should be willing to provide hypotensive anesthesia with a target systolic blood pressure of 90 m m H g whenever possible. For surgeons using the lateral decubitus position, turning the table 180 ° so that the anesthesiologist is at the patient's feet greatly enhances the space available for the operating team to carry out the repair. It is invaluable to prepare the team for an arthroscopic repair by performing an in-service on the technique and on surgeon preferences.
PERFORMING ARTHROSCOPIC CUFF REPAIR
PATIENT POSITIONING
SELECTING THE FIRST TEAR FOR ARTHROSCOPIC CUFF REPAIR Once the surgeon is comfortable with the steps of an arthroscopic rotator-cuff repair and is ready to attempt its use in practice, it is important to begin selecting tears that may be appropriate for the initial arthroscopic repair. Small tears are obviously easier to repair than larger tears, which may require the use of several anchors and sutures. In addition, tears that are not significantly retracted are easier because less mobilization is required. Finally, a partial-thickness tear is a poor initial candidate for arthroscopic repair because establishing whether or not a repair is necessary requires an assessment of tear size and tear depth that may be difficult to perform arthroscopically. Additionally, the exact location of the tear is often difficult to identify, even after tagging the site with a suture, because the tear may involve only the articular surface and may not extend to the bursal surface.
ASSEMBLING YOUR TEAM
Surgical Assistance An experienced surgeon without an experienced team will encounter great hardship during the transition to an arthroscopic rotator-cuff repair. Although examples certainly exist of surgeons performing repairs without an assistant, the procedure is greatly facilitated by a competent first assistant who is trained specifically in all aspects of his technique as well as by a scrub nurse or tech that is familiar with the equipment used. Conducting an "Inservice" before using new equipment helps explain proper usage and underlying rationale to the operating room staff. The senior author performs all his arthroscopic rotator-cuff repairs jointly with the same assistant.
ANESTHESIA In addition to a well-trained orthopaedic team, a competent anesthesiologist is also essential. Interscalene block
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The decision on whether to use sitting (beach chair) or lateral decubitus position is one that the individual surgeon needs to make. The senior author uses the sitting position for both rotator-cuff and glenohumeral repairs but other surgeons prefer the lateral decubitus position. Proponents of the lateral decubitus position point to the ease of positioning the arm with a traction device and to advantages with glenohumeral visualization, especially posteriorly. Proponents of the beach-chair position point to the fact that the subacromial space can be positioned so that it is parallel to the floor, which may facilitate the repair as well as the ease of conversion to an open approach if necessary. However, because the mini-open approach can be performed in both positions, the surgeon should focus on mastering the steps to an arthroscopic repair and not try to alter positioning. Regardless of whether the decubitus or beach-chair position is preferred, patient positioning is critical to the success of the procedure. In the beach-chair position, the patient's torso should be flexed forward so that the acromion is as horizontal as possible. Posterior acromial slope varies from patient to patient and failure to position the patient so that the acromion (and subacromial space) is parallel to the floor results in the surgeon directing the arthroscope more vertically and having to work "uphill." Additionally, the field should be generously draped posteriorly, both for portal placement and for instrument manipulation. The use of the Schloein positioner (Orthopedic Systems, Union City, CA) greatly facilitates patient positioning for the senior author. The device allows the patient to sit upright and affords sufficient access to the posterior shoulder without requiring that the patient be translated laterally to the edge of the operating table. The patient's arm is controlled with a McConnell arm holder (McConnell Orthopedics, Greenville, TX) without occupying the assistant. The holder is invaluable in maintaining proper arm rotation so that the repair site is directly underneath the operating cannula. Rotating the table 45 ° with respect to the room also increases the space available for both the surgeon and assistant. HASAN AND GARTSMAN
ARTHROSCOPIC PORTALS
An arthroscopic rotator-cuff repair can be performed by using 3 portals: posterior, anterior, and lateral. Although these portals are used routinely during arthroscopic subacromial decompression, they must be positioned with greater precision to enable rotator-cuff repair. The senior author places the posterior portal nearer to the posterolateral corner of the acromion than traditional placement in the soft spot, typically 1 cm medially and 1-1.5 cm inferiorly. This ensures that the arthroscope can be inserted superiorly within the subacromial space to maxirnize the distance from the arthroscope to the rotator cuff, This creates "a room with a view" that allows for careful inspection of the rotator cuff and facilitates visualizatkm during the repair. STEPS OF AN ARTHROSCOPIC CUFF REPAIR
An arthroscopic rotator-cuff repair proceeds systematically in a logical step-wise fashion. The essential steps to a repair include visualization and decompression, inspection, abrasion of the foot print, anchor insertion, suture passage through tendon, and arthroscopic knot tying. Failure to perform adequately any of these steps will lead to failure of the repair. The details of an arthroscopic rotatorcuff repair have been described in previous articles by the senior author!°, a2-24 and by others. 2,4 In the sections that fol!ow, we wi!l describe some common pitfalls and share some pearls that may be worth remembering. DIAGNOSTIC ARTHROSCOPY
A careful yet efficient diagnostic arthroscopy should precede every rotator-cuff repair. The arthroscope is placed posteriorly and directed into the glenohumeral joint. The labrum, biceps, subscapularis, rotator interval, and both glenoid and humeral head articular surfaces should be inspected carefully' A probe inserted through an anterior cannula often helps here. The rotator-cuff footprint should be respected to confirm a full-thickness tear or to evaluate any partial tearing. The arthroscope can also be placed anteriorly to evaluate the posterior rotator cuff and la-bruin. Lesions that are identified are treated accordingly, including repair of labral tears and debridement. However, modest debridement of the various structures is not performed because it contributes little if anything to the patient,s condition In addition, time wasted unnecessarily o n debridement m a y limit the time available to carry out the repair if fluid extravasation and swelling occur. When a smal ! rotator,cuff tear is identified, placement of a suture marker may be helpful, although this is not performed r o u ~ e l y by the serdor author. This can be performed by using a 0-PDS passed through an 18-gauge spinal needle inserted from lateral or anterolateral into the site of the tear iCapsular releases may be performed on the articular side as needed during the glenohumeral arthroscopy. SUBACROMIAL DECOMPRESSION
Subacromial decompression is performed in routine fashion. 25-28 The arthrosc~pe is inserted through the posterior PEARLSAND PITFALLS;OF ARTHROSCOPICROTATOR-CUFFREPAIR
portal and directed toward the anterior acromion. Gentle medial to lateral sweeps performed with the sheath may enhance visualization. A lateral portal is established 2 cm distal and 2 cm posterior to the anterolateral corner of the acromion. Once the portal is established, a bursectomy is performed by using both a shaver and electrocautery, which allows for careful visualization of the bursal surface of the rotator-cuff tear. The reparability of the tear is determined before an acromioplasty is performed. 29 A tissue grasper is used to pull on the tear edge so as to determine the repair-site location. Varying both the direction of the pull and the degree of arm elevation and rotation is often required. 23 Typically the arm is positioned in 20 ° of elevation, 15 ° of abduction, and 10° of internal rotation. The arm is maintained in this position with the McConnell arm holder. Once reparability has been determined, the coracoacromial ligament is released and resected and an acromioplasty is performed by using a standard cutting-block technique. 2s The goal of the acromioplasty is to increase the volume of the subacromial space by converting a type 2 or 3 acromion to a flat, type 1 acromion. The inferior lateral acromion is thinned further if a lateral slope is identified on a magnetic resonance imaging scan or plain radiographs. An aggressive acromioplasty is not essential for an arthroscopic rotator-cuff repair and there is no need to perform an acromioplasty of a type I acromion. Indeed, the acromioplasty can be omitted altogether, thereby preserving the coracoacromial ligament, in situations whether the tendon tissue is of questionable quality and the healing of the repaired tendon is less predictable. Alternatively, electrocautery can be used to release, rather than resect, the ligament off the undersurface of the acromion. Proper placement of the arthroscopic portals and deft manipulation of the arthroscope are more important than an aggressive acromioplasty to create the "room with a v'lew" that facilitates arthroscopic rotator-cuff repair. TEAR VISUALIZATION
Once adequate bursa has been resected to allow visualization of the rotator-cuff tear, its morphology must be characterized in detail. This can be accomplished frequently with the arthroscope located posteriorly, but the surgeon should not hesitate to inspect the tear from the lateral portal to obtain the so-called "50-yard line view." With small to medium tears less than 3 cm in length, the size and tear geometry is often easily appreciated. Tear size is measured by comparing it to the known diameter of the lateral carmula. The length of the tear from anterior to posterior as well as the amount of medial retraction is noted. Straight medial retraction producing an elliptical defect is most common_ As tear size increases, the ability to appreciate tear geometry becomes more difficult. Reverse "L" tears with a longitudinal component along the rotator interval allow the tear to rotate posteriorly. "L"shaped tears have a longitudinal limb posteriorly, often at the junction of the supraspinatus and infraspinatus, in addition to lateral d e t a ~ e n t from the greater tuberositv. Longitudinal tears may occur in the area of the rotator interval and occasionally within the supraspinatus tendon. 1 '79
Only when tear geometry is appreciated can an effective repair be performed.
ROTATOR-CUFF MOBILIZATION Mobilizing a retracted rotator-cuff tear is a critical step in the repair. Adhesions often form with the subacromial space between rotator cuff and acromion or deltoid, interfering with tendon mobilization and frequently giving a false impression of irreparability. Dense adhesions between the anterior margin of the tear and coracoid often form, especially around the coracohumeral ligament, and these require release with electrocautery. A power shaver is not used so as to prevent bleeding that is often difficult to control, owing to the medial location of the bleeding vessels. Posterior adhesions usually are not as dense and can often be released b y inserting a metal trocar and cannula through the lateral portal, placing it superior to the anterior tear edge and sweeping posteriorly directly beneath the acromion. Electrocautery can also be used if the adhesions are especially thick. Adhesions may also form on the articular surface of the tendon between cuff and superior glenohumeral joint capsule and labrum that require intra-articular release.
SIDE-TO-SIDE REPAIR AND MARGIN CONVERGENCE Once tear geometry has been established, the repair must be visualized exactly as it will be performed. Specifically, the precise location of the anchors and various stitches and the exact sequence of repair steps should be thought out before undertaking the repair. For large tears with an L or reverse-L shape the longitudinal split is first repaired in side-to-side fashion from medial to lateral, and then the transverse distal portion is repaired to bone with suture anchors. If the tear has a U-shaped configuration, such as the degenerative tear that is retracted, then the tear size should be diminished by first repairing the medial aspect with a side-to-side technique and then repairing the remaining tear to bone with suture anchors. This technique is referred to as margin convergence and was popularized by Burkhart. 3 The advantages of this technique are that it decreases the forces acting at the repair site and helps "converge" the tear toward its footprint, thereby decreasing the tendon tear size.
decorticates the bone to a depth of 1-2 mm and a width of roughly 1 cm in order to create a cancellous bed for the tendon (Fig 1). 23 A deeper trough, commonly performed during open repair, has not been found to be necessary. A deep trough may also lead to loss of effective rotator-cuff length and increase the tension across the repair. Tendon tear length determines the anterior-to-posterior dimension of the repair site.
REPAIR STRATEGIES AND USE OF SPECIALIZED INSTRUMENTS Once the locations of the various sutures are visualized the next step is to decide which techniques will be used to pass the sutures through tendon. In general there are 2 basic types of techniques: direct or shuttle. Direct techniques use instruments that directly pass the suture through the tendon. Examples of these instruments are the Cuff Stitch and Arthropierce (Smith-Nephew Endoscopy, Andover, MA), Viper (Arthrex, Naples, FL) and Penetrator (Arthrex), and Blitz (Linvatec, Largo, FL). Shuttle techniques use instruments that first pass a suture or wire shuttle through tendon. The shuttle then is used to pass the actual suture through tendon. Instruments used to shuttle wire or suture include the Caspari punch (Linvatec) and the Spectrum Suture Needles (Linvatec). The Spectrum device can also be used to pass s u c r e directly, such as for a side to side repair with monofilament suture. Determining whether to use a direct or shuttle technique depends on the geometry or the tear as well as on the prepared working portal. In general if the lateral portal is the working portal then a direct technique works best for the side to side repair such as during margin convergence. In contrast the shuttle technique is best suited for repairing the tendon directly to bone. Both techniques require a meticulous attention to detail. Side-to-side repairs are performed by using permanent braided or monofflament sutures or slowly absorbable monofilament suture such as O-polydioxanone suture (OPDS). Typically, a suture passer is inserted through the anterior portal while viewing through the lateral portal; the suture is passed in simple fashion across the split. Anterior tears, such as those with a rotator interval split,
PREPARING THE ROTATOR CUFF Before suture repair, the tendon edges should be gently debrided to remove devitalized tissue and promote healing. The debridement should aim to refresh the tendon edge rather than to remove it, so as not to jeopardize the repair. Debriding 1 or 2 millimeters of tendon edge is all that is necessary. More extensive debridement may shorten the tendon and result in a nonanatomic repair or one that is under excessive tension.
PREPARING THE REPAIR SITE The repair site must be prepared at the rotator-cuff footprint just lateral to the articular margin before initiating tendon-to-bone repair. A 4-mm arthroscopic round bur
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Fig 1. Decortication of the rotator-cuff footprint.
HASANANDGARTSMAN
I(
%
Fig 3. Arthroscopic view of lateral suture anchor placement.
9,
Fig 2. Lateral placement of suture anchor ("deadman's angle").
require a coiled or sharply angled suture passer or retriever. Both suture ends are retrieved out the posterior portal so that arthroscopic techniques can be used to tie the knot. A sliding ];not such as the Duncan loop, followed by 3 half hitches, is typically used to tie monofilament suture. 30 ANCHOR
INSERTION
The number of anchors depends on the length of the rotator-cuff tear. For all but the smallest tears, 2 suture anchors are used; massive (>5 cm) tears may require 3 or 4 anchors. Currently available suture anchors are loaded with either 1 or 2 sutures. Those with 2 sutures are preferred because they disperse loads more efficiently, but these require additional suture-management skills. In addition, #2 nonabsorbable suture is preferred, although some surgeons use slowly absorbable braided suture such as Panacryl TM. The use of different-colored sutures aids in suture identification and management. Although some surgeons elect to place the anchors into the rotator-cuff footprint there are a number of reasons for more lateral placement of the anchors. Burkhart has written about the mechanical advantage of inserting anchors so that they are directed 45 ° inferomedially, or at a "deadman's" angle. 31 This orientation places the line of pull 90 ° to the direction of the anchor, which minimizes anchor pullout (Fig 2). Lateral anchor position permits an anatomic repair because the tendon is pulled laterally toward the tendon bed. The anchor is placed in bone with an intact PEARLS AND PITFALLS OF ARTHROSCOPIC ROTATOR-CUFF REPAIR
cortical surface instead of the prepared cancellous bed at the repair site. Lateral anchor placement also enables the sutures to be tied laterally; this may limit suture impingement, a frequent postoperative nuisance. Avoiding the footprint increases the area available for tendon to bone healing. An 18-gauge spinal needle can be inserted through the lateral portal to determine the appropriate angle for anchor insertion (Fig 3). Some anchors require predril!ing and others do not; some anchors are pushed into place and others are screwed into place manually. To minimize the potential for anchor migration32 it is important to verify adequate anchor purchase and proper insertion. This is accomplished by tugging firmly on the sutures once the anchor has been inserted while viewing the insertion site arthroscopically. Most anchors have oblong eyelets so that the final ori~ entation of the anchors is important. In general, anchors should be inserted such that the eyelet is parallel to the tendon edge instead of facing the edge. Most anchors are inserted with devices that clearly mark the location of the eyelet to facilitate proper orientation (Fig 4). This is to
Fig 4. Arthroscopic view of metallic suture anchor attached to insertion device. The vertical mark on the inserter identi, ties the orientation of the eyelet. 1 81
Typically, all the suture anchors are inserted and the suture limbs retrieved before passing the sutures through the free tendon edge. Suture anchors are always inserted in the same sequence from anterior to posterior so that those anchors already in bone do not impair visualization as subsequent anchors are inserted. This order also minimizes the likelihood of suture entanglement because the sutures that are retrieved from the first anchor through the anterior portal remain anterior to any subsequent anchor.
SUTURE PLACEMENT
Fig 5. Close-up of suture anchor eyelet. The suture makes a 90 ° turn with respect to eyelet, which minimizes suture abrasion.
prevent one suture limb from taking an 180 ° turn as the suture is tied. This is especially true when using metallic anchors, especially those with sharp edged eyelets that may abrade the suture. This may be less important for bioabsorbable anchors, whose eyelets are round and blunt or made of suture. If the anchor used requires predrilling, make sure that no suture limbs are within the subacromial space before drilling or they will become entangled. In addition, if the anchor is inserted so that the eyelet is parallel to the tendon edge, then either suture limb can be passed through tendon. If the eyelet is perpendicular, then there is a 50% chance that the limb selected for passage will make a 180 ° turn as it exits the eyelet, leading to potential abrasion of the suture (Fig 5).
Once the anchors are inserted and their sutures retrieved, the sutures are passed through tendon. The soft-tissue grasper is passed through the lateral cannula, and the precise location for the tendon repair as well as the location and spacing of each suture is estimated. We space the sutures evenly from anterior to posterior margin. The sutures are passed through tendon from anterior to posterior. Although various techniques exist for passing suture through tendon, a rather straightforward technique uses a Caspari suture punch to pass a suture relay that then is used to pass the suture from the anchor across the tendon. The Caspari suture punch cannot be used to pass the suture directly because it will not accept a #2 braided suture. The device is loaded with a 2-0 nylon suture that is folded in half so that the 2 free ends are just beneath the needle tip and the looped end exits from the handle. The device is inserted through the lateral portal and aimed at the portion of tear corresponding to the anchor. The device grasps and punctures the tendon 5 mm medial to the tendon edge, until the needle is visible on the bursal surface (Fig 6). When using a suture anchor loaded with 2 sutures the surgeon should know the order in which the sutures are loaded. The order is important when the geometry of the eyelet forces the sutures to be stacked. In this
SUTURE PLACEMENT, SUTURE PASSAGE, AND KNOT TYING Suture Retrieval After each suture anchor has been inserted, the sutures are retrieved by using a crochet hook or similar device. The crochet hook is usually inserted through the anterior portal. However, when performing repairs of large rotatorcuff tears requiring 2 or more anchors, the sutures may be retrieved percutaneously from an anterolateral stab incision, which helps considerably with suture management.
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Fig 6. Close-up of suture anchor eyelet showing stacked arrangement of the 2 #2 nonabsorbable sutures.
HASANANDGARTSMAN
Fig 8. The 2 free ends of #2-0 nylon suture are withdrawn through the anterior cannula by using a crochet hook or similar device.
Fig 7o Caspari suture punch through the edge of the rotator= cuff tendon. Two free ends of #2-0 nylon suture protrude just past the tip of the needle, A crochet hook has been inserted through the anterior portal to push down on the tendon and facilitlate puncture of the tendon.
case, the top suture is passed first so that it may be tied first "without binding the bottom suture (Fig 6). The Caspari suture punch was originally intended to pass a braided wire shuttle across the tendon. However, a 2-0 nylon suture shuttle is far less expensive and the wire shuttle may cause tissue abrasion. Dr. Snyder has modified the Caspari suture punch so that the end of the punch is slotted. This greatly facilitates removal of the punch once the suture shuttle has been passed. To puncture the thicker tendons often seen in younger adults, the senior author has lengthened the needle at the tip of the suture punch. These modifications are available commercially. Pushing on the tendon near the Caspari suture punch by using the crochet hook inserted anteriorly facilitates passage of the device through tendon (Fig 7). This provides the countertraction that is often needed when the tendon is thick.
punch is withdrawn, the looped end of the suture shuttle projects out the lateral cannula. Next, one of the anterior suture anchor strands is retrieved out the lateral cannula by using a crochet hook. When double-loaded anchors are used, 1 limb of the topmost suture is selected to be passed first. A hemostat clamps the remaining anterior suture anchor strand. Approximately 3 inches of the braided suture is placed within the loop of the 2-0 nylon suture external to the lateral cannula. If less than 3 inches of suture are passed through the loop then it may uncouple from the suture shuttle as the shuttle is passed through the tendon. Whenever a suture limb shares a cannula with a suture shuttle, it is critical to check that they are not entangled before the limb is coupled to the shuttle. A suture retrieval forcep is inserted through that cannula into the subacromial space and both strands of nylon suture are enclosed within the jaws of the suture-retrieval forceps. The jaws are kept closed around the 2 nylon suture strands as the retrieval forceps is removed from the cannula (Fig 9). This
COMPLETING THE RELAY
Once the free ends of the shuttle are delivered into the subaeromia! space, a crochet hook is used to retrieve both ends out the anterior portal (Fig 8). The assistant applies a hemostat to the suture ends so that they are not accidentally pulled back into the subacromial space. After the shuttle ends are retrieved, the jaws of the Caspari punch are opened as the device is withdrawn from the tendon and then :the lateral cannula. A gentle d o w n w a r d push on the Caspari suture punch facilitates its withdrawal from the tendon. Failure to do so may lacerate the shuttle suture ends against t h e needle tip, in which case the Caspari suture punch must be reloaded. Once the Caspari suture PEARLS AND PITFALLS OF ARTHROSCOPIC ROTATOR-CUFF REPAIR
Fig 9. The suture retrieval forceps ensure that sutures are not entangled. 183
step should be repeated for each braided suture in order to ensure that it is not entangled with the nylon shuttle. Traction is placed on the 2 free ends of the nylon suture anteriorly and the braided suture is pulled from the lateral carmula into the subacromial space, through the tendon, and out the anterior cannula. At this point, a simple suture has been placed through the rotator cuff (Fig 10). The 2 suture limbs from the anchor are clamped and ready to be tied. These steps are repeated as necessary. While viewing the repair from posterior, the knots should generally be tied from posterior to anterior, although the surgeon may modify this according to tear geometry. Each knot should be tied and suture limbs cut before proceeding to the next knot in order to minimize clutter in the subacromial space. Various suture techniques to place mattress (easily performed by using the suture shuttle to pass both suture strands) and MasonAllen stitches have been performed but they are cumbersome and time consuming. We prefer to use simple sutures to repair all sizes of rotator-cuff tears and have not experienced problems with suture pullout.
ARTHROSCOPIC KNOT TYING It is important to master at least i sliding and I nonsliding knot. In general, sliding knots are best suited for monofilament suture such as PDS and nonsliding knots are best for braided suture, which may not slide as well. Nottage and Lieurance have written an excellent review on arthroscopic knot tying, s° which includes detailed illustrated instructions for tying various sliding and nonsliding knots. The importance of truly mastering arthroscopic knot tying can not be overstated. An arthroscopic repair that has been carefully planned and executed will certainly fail if the sutures are not tied in such as manner that both loop security and knot security are achieved. Loop security is achieved by maintaining tight suture loops before knot tying, as whereas knot security is the effectiveness of a given knot at resisting slippage. 34 Arthroscopic knot tying should be practiced first on a knot-tying board with rope to learn the general concepts, and then practiced further with suture and instruments.
Arthroscopic knot tying uses instruments in place of the surgeon's fingers to deliver and secure the knot. These instruments include slotted or closed knot pushers, some of which can be used as pushers/pullers, as well as specialized instruments such as the 6th Finger (Arthrex, Naples, FL). The surgeon should try various instruments and determine which one works best.
ARTHROSCOPIC KNOT TYING: STEPS The first step in tying an arthroscopic knot is to deliver the suture limbs to the portal that will be used to tie the knots. With the arthroscope in the posterior portal, the suture limbs are delivered from the anterior cannula to the lateral cannula. A suture-retrieval forcep encloses i of the 2 limbs in the subacromial space and is removed from the lateral cannula while its jaws are closed to ensure that the limbs are not entangled. The next step is determining which suture limb is the post. The suture limb that has not been passed through tendon serves as the initial post so that the throws lie flat. The post limb is threaded through the knot pusher and the end of the limb is clamped with a hemostat. The knot is made and the knot pusher pushes the knot down the cannula to the tissue. It is important to visualize arthroscopically the knot as it descends to make sure that it lays flat. Gently rotating the knot pusher helps with this. Once the knot is flat, the pusher can be used as a "puller" by pass pointing on the suture limb to help cinch it. Harryman et al have shown that alternating the direction of the half hitches and alternating posts optimize the security of the repair. 35,36 Three half hitches are needed to secure a sliding knot or a nonsliding knot. Burkhart and Chan have described a technique for reversing the post without actually threading the other limb through the knot pusher. 37 To accomplish this, differential tension is applied on the 2 suture limbs, which causes the knot to "flip," resulting in a reversal of the post. This change in post can be directly viewed arthroscopically. This technique saves time by eliminating multiple manipulations of the knot pusher. Once the knots have been tied and secured with additional half hitches, the suture ends are cut by using any of several available arthroscopic scissors so that 3 to 4 mm ends remain.
KNOWING WHEN TO SAY WHEN It is useful to remain aware of the clock during an arthroscopic rotator-cuff repair. The surgeon should always be willing to convert to a mini-open repair after a certain time has elapsed or in situations when significant fluid extravasation has occurred.
POSTOPERATIVE
Fig 10, Arthroscopic view showing a completed simple pass of #2 nonabsorbable suture through the tendon,
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MANAGEMENT
Rehabilitation after arthroscopic rotator-cuff repair is essentially the same as that after open or mini-open repair. 23 Although the skin incisions are smaller and the deltoid attachment is preserved, all elements of an open repair are performed in an arthroscopic repair. Consequently, the repaired tendon or tendons need to be protected, typically for 4 - 6 weeks. HASAN AND GARTSMAN
Patients are admitted overnight for pain management. Initial emphasis is placed on recovering passive range of motion. Patients use a continuous passive-motion chair in the hospital and for 2 weeks at home to aid in recovery of passive motion. The machine moves the arm in elevation and then in external rotation through safe limits that are established at the time of surgery. Patients are cautioned not be begin active shoulder motion too early. This is a concern because many patients are off of narcotic analgesics in a matter of days or a couple of weeks and begin to feel "good" before the tendon has healed adequately. Patients begin active assisted range of motion 6 weeks after surgery, at which time they may slowly resume arm use during activities of daily living. Driving is generally allowed 2 weeks after surgery. Strengthening is instituted at 3 months and the rehabilitation continues for 12 months as needed. Patients often return to low-demand jobs within a week or 2 but return to unrestricted repetitive overhead work or sport may take 6 months or longer.
REFERENCES 1. Snyder SJ, Foos GR: Arthroscopic treatment of bursal side and full thickness rotator cuff tears. Ann Chir Gynaecol 85:117-125, 1996 2. Snyde r SJ: Technique of arthroscopic rotator cuff repair using implantable 4-ram Revo sutazre anchors, suture Shuttle Relays, and no. 2 nonabsorbable mattress sutures. Orthop Clin North Am 28:267-275, 1997 3. Burkhart SS, Athanasiou KA, Wirth MA: Margin convergence: A method of reducing strain in massive rotator cuff tears. Arthroscopy !2:335-338, 1996 4. Burkhart SS: A stepwise approach to arthroscopic rotator cuff repair based on biomechanicat principles. Arthroscopy 16:82-90, 2000 5. Gazielly DF, Gleyze P, Montagnon C, etal: Arthroscopic repair of distal supraspinatus tears with Revo Screw and permanent mattress sutures: A preliminary report. Presented at the American Shoulder and Elbow Surgeons 13th Annual Meeting, Amelia Island, FL, 1996 6. Paulos LE, Kody MH: Arthroscopically enhanced "miniapproach" to rotator cuff repair; Am J Sports Med 22:19-25, 1994 7. Blevins FT, Warren RF, Cavo C, et al: Arthroscopic assisted rotator cuff repair: Results using a mini-open deltoid splitting approach. Arthrescopy 12:50-59, 1996 8. Bachner EJ, Snyder SJ: Arthroscopic subaeromial decompression, arthroscopic-assisted (mini-open) rotator cuff repair, and arthroscopic cuff repair, in Burkhead WZ Jr (ed). Rotator Cuff DisorderS. Baltimore, Williams & Wilkins, 1996, pp 271-289 9, Gartsman GM I C0rabined arthroscopic and open treatment of tears of the rotator cuff ~J Bone Joint Surg 79A:776-783, 1997 10. Gartsman GMi Hammerman SM: Full-thickness tear: Arthroscopic repairl Orth Clin North Am 28:83-98, 1997 11. Warner JJ, Goit~ I~l, Irrgang JJ, et al: Arthroscopic-assisted rotator cuff repair: Patient selection and treatment outcome. J Shoulder Elbow Surg 6:463±472, 1997 12. Gartsman GM: Arthroscopic management of rotator cuff disease. J Am Acad Orthop Surg 6:259-266, 1998
PEARLS AND PITFALLS OF ARTHROSCOPIC ROTATOR-CUFF REPAIR
13. Norberg FB. Field LD, Savoie FH III: Repair of the rotator cuff. Mini-open and arthroscople repairs. Clin Sports Med 19:77-99, 2000 14. Murray TF Jr, Lajtai G, Mileski RM, et ah Arthroscopic repair of medium to large full-thickness rotator cuff tears: Outcome at 2- to 6-year follow-up. J Shoulder Elbow Surg 11:19-24. 2002 15. Gartsman GM. Brinker MR, Khan M: Earlv effectiveness of arthroscopic repair for full-thickness tears of the rotator cuff - an outcome analvsis. J Bone Joint Surg 80A:33-40, 1998 16. Gartsman GM, Khan M, Harnmerman SM: Arthroscopic repair of full-thickness rotator cuff tears. J Bone Joint Surg 80A:832-840, 1998 17. Stollsteimer GT, Savoie FH III: Arthroscopic rotator cuff repair: Current indications, limitations, techniques, and results. Instr Course Lect 47:59-65, 1998 18. Tauro JC: Arthroscopic rotator cuff repair: Analysis of technique and results at 2- and 3-year follow-up. Arthroscopy 14:45-51, 1998 19. Gerber C, Fuchs B, Hodler J: The results of repair of massive tears of the rotator cuff. J Bone Joint Surg 82A:505-515, 2000 20. Yamaguchi K: Mini-open rotator cuff repair: An updated perspective. Instr Course Lect 50:53-61, 2001 21. Yamaguchi K, Ball CM, Galatz LM: Arthroscopic rotator cuff repair: Transition from mini-open to alI-arthroscopic. Clin Orthop 390:83-94, 2001 22. Gartsman GM, Hammerman SM: Arthroscopic repair of full-thickness rotator cuff tears: Operative technique. Op Tech Orth 8:226-235. 1998 23. Gartsman GM, Hammerman, SM: Arthroscopic repair of full-thickness rotator cuff tears. Op Tech Shoulder Elbow Surg 1:2-8, 1999 24. Gartsman GM: Arthroscopic rotator cuff repair. Clin Orthop 390:9510G 2001 25. Ellman H: Arthrscopic subacromial decompression: Analysis of one to three year results. Arthroscopy 3:173-t81, 1987 26. Ellman H, Kay SP: ArthroscopK subacromial decompression for chronic impingement. Two- to five year results. J Bone Joint Surg Br 73:395-398, 1991 27. Gartsman GM, Blair ME, Noble PC, et al: Arthroscopic subacromial decompression. An anatomical study. Am J Sports Med 16:48-50, 1988 28. Gartsman GM: Arthroscopic acromioplasty for lesions of the rotator cuff. I Bone Joint Surg 72A:169-180, 1990 29. Gartsman GM: Arthroscoplc assessment of rotator cuff reparability. Arthroscopy 12:546-549, 1996 30. Nottage WM, Lieurance RK: Arthroscopic knot tying techniques. Arthroscopy 15:515-521, 1999 31. Burkhart SS: The deadman theory of suture anchors: Observations along a south Texas fence line. Arthroscopy 11:119-123, 1995 32. Weber SC, Abrams JS, Nottage WM: Complications associated with arthroscopic shoulder surgery. Arthroscopy 18(suppl):88-95, 2002 33. Burkhart SS, Wirth MA, Simonich M, et al: Loop security as a determinant of tissue fixation security. Arthroscopy 14:773-776, 1998 34. Burkhart SS, Wirth MA, Simonich M, et al: Knot security in simple sliding knots and its relationship to rotator cuff repair: How secure must the knot be? Arthroscopy 16:202-207, 2000 35. Loutzenheiser TD, Harryman DT 1I, Yung SW, et al: Opthnizing arthroscopic knots. Arthroscopy 11:199-206. 1995 36. Loutzenheiser TD, Harryman DT I1, Ziegter DW, et al: Optimizing arthroscopic knots using braided or monofilament suture. Arthroscopy 14:57-65, 1998 37. Chan KC, Burkhart SS: How to switch posts without rethreading when tying half-hitches. Arthroscopy 15:444-450, 1999
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