shoulder•opsurg-619

Arthroscopic Rotator Cuff Repair

intermediate Level

Primary Indication

Symptomatic full-thickness rotator cuff tear with failed conservative management (minimum 3-6 months physiotherapy, NSAIDs, corticosteroid injection)

Danger Structures

undefined (15-20mm medial to glenoid rim at spinoglenoid notch level) - Runs through suprascapular notch beneath superior transverse scapular ligament, then around spinoglenoid notch to infraspinatus
undefined (5-7mm inferior to inferior glenoid rim, approximately 5cm inferior to acromion) - Exits posterior through quadrangular space with posterior circumflex humeral artery, passes anteriorly around surgical neck 5-7mm inferior to inferior glenoid
undefined (3-5cm medial and inferior to anterior portal) - Branches from lateral cord, pierces coracobrachialis muscle belly 5-8cm distal to coracoid tip
undefined (0mm at deltopectoral interval) - Runs in deltopectoral groove between deltoid laterally and pectoralis major medially
undefined (Immediate - within field of view) - Originates from supraglenoid tubercle, runs through rotator interval between supraspinatus and subscapularis

Visual Atlas

Step-by-Step Technique

Patient positioning and portal planning: Position patient in beach chair (30-45° head elevation) or lateral decubitus (70-90° tilt). Ensure anaesthetic comfortable with position. Mark bony landmarks: acromion borders, AC joint, coracoid. Plan posterior portal (soft spot), anterior portal (rotator interval), lateral portal (for anchors). Prepare and drape entire upper limb free including hand

Surgeon's Tip

EXAM KEY: Positioning affects exposure and instrument triangulation. Beach chair allows easier conversion to open, better hypotensive anaesthesia, but may have instrument 'sagging'. Lateral decubitus provides better visualization but requires experienced anaesthetist. Use 3-5kg traction in lateral position, 10lbs maximum to avoid traction neuropraxia

Danger Zone

Iatrogenic injury to adjacent structures

Establish posterior portal and diagnostic arthroscopy: Palpate soft spot (interval between infraspinatus, teres minor, posterior deltoid) 2cm inferior and 2cm medial to posterolateral corner of acromion. Insert spinal needle to confirm trajectory into glenohumeral joint. Make 5mm skin incision. Use blunt trocar to enter joint, insert 30° arthroscope. Systematic 15-point glenohumeral examination: biceps anchor and intra-articular portion, superior labrum, rotator interval, subscapularis, anterior labrum, inferior labrum, posterior labrum, glenoid articular surface, humeral head articular surface, posterior capsule

Surgeon's Tip

EXAM KEY: Posterior portal is primary viewing portal for entire case. Too superior risks supraspinatus injury. Too medial risks suprascapular nerve. Confirm intra-articular position before advancing camera - see cartilage and synovium. Systematic diagnostic arthroscopy is essential - don't miss associated pathology (SLAP lesion, biceps tear, subscapularis tear, cartilage damage). Document with photographs/video

Danger Zone

Skin necrosis from excessive tension
Damage to underlying structures

Establish anterior portal via rotator interval: Visualize from posterior viewing portal. Insert spinal needle through rotator interval (between supraspinatus superiorly and subscapularis inferiorly) aiming for glenohumeral joint. Entry point approximately 1cm inferior and 1cm lateral to anterolateral corner of acromion. Confirm needle trajectory under direct vision. Make 5mm incision. Insert cannula or switching stick. This becomes primary working portal

Surgeon's Tip

EXAM KEY: Anterior portal placement is critical - too medial risks musculocutaneous nerve, too lateral limits working space. Rotator interval is internervous plane. Confirm needle position before making incision - should pass anterior to biceps tendon into joint. Use cannula to maintain portal and prevent soft tissue creep. Outside-in technique preferred (needle first) vs inside-out (switching stick from inside)

Danger Zone

Skin necrosis from excessive tension
Damage to underlying structures

Assess rotator cuff from glenohumeral side and evaluate biceps tendon: View from posterior portal, instrument from anterior portal. Examine rotator cuff articular surface - crescent tears (most common), L-shaped tears (anterior extension to rotator interval), U-shaped tears (anterior and posterior extensions), massive tears (>5cm). Assess tear retraction (Patte classification: grade 1 <1cm, grade 2 1-3cm, grade 3 >3cm). Probe biceps tendon: assess stability (subluxation over medial bicipital groove edge suggests subscapularis insufficiency), integrity (>50% thickness tear indicates tenotomy/tenodesis), SLAP lesion association. Document findings

Surgeon's Tip

EXAM KEY: Biceps pathology present in 30-40% of rotator cuff tears. Hourglass biceps, >50% tear, instability, SLAP type II-IV all indicate biceps tenotomy or tenodesis. Tenotomy simpler (intra-articular release) but may cause Popeye deformity, cramping, slight strength loss. Tenodesis (arthroscopic or open suprapectoral) maintains length-tension relationship but more complex. Tear pattern affects repair strategy - crescent tears require single fixation line, L-shaped and U-shaped tears require sequential repair (margin convergence then footprint)

Danger Zone

Iatrogenic injury to adjacent structures

Transition to subacromial space and perform bursectomy: Remove arthroscope from glenohumeral joint. Redirect posteriorly into subacromial space - enter between acromion and cuff, use blunt trocar carefully. Establish anterior subacromial portal using outside-in technique (spinal needle visualization). Insert motorized shaver through anterior portal. Perform systematic bursectomy to visualize cuff tear from bursal surface, acromial undersurface, CA ligament, AC joint. Complete bursectomy anteriorly over coracoid, laterally over greater tuberosity, posteriorly to visualize infraspinatus

Surgeon's Tip

EXAM KEY: Thorough bursectomy is essential for visualization - subacromial bursa can be thick, vascular, inflammatory. Use arthroscopic shaver in cutting mode (not suction mode) for efficiency. Identify landmarks: anterolateral acromion, CA ligament, posterior acromion, greater tuberosity footprint. Control bleeding with radiofrequency ablation or epinephrine in arthroscopy fluid (1:300,000). Full bursectomy also serves as partial acromioplasty by decompressing subacromial space

Danger Zone

Iatrogenic injury to adjacent structures

Assess cuff tear pattern, retraction, and tissue quality from bursal side: View tear from subacromial space. Classify tear size (Cofield: small <1cm, medium 1-3cm, large 3-5cm, massive >5cm). Assess retraction using Patte classification: Grade 1 tear remains lateral to greater tuberosity, Grade 2 retracted to glenoid level, Grade 3 retracted medial to glenoid. Evaluate tissue quality: friable edges, thinning, muscle atrophy visible. Assess fatty infiltration pre-operatively on MRI (Goutallier staging: 0 normal, 1 fatty streaks, 2 <50% fat, 3 50% fat, 4 >50% fat). Grade 3-4 suggests poor healing potential

Surgeon's Tip

EXAM KEY: Tear size and tissue quality are most important prognostic factors. Large-massive tears with poor tissue quality (Goutallier 3-4) have re-tear rates 40-60%. Consider augmentation (patches, grafts) or alternative procedures (SCR, reverse arthroplasty) for poor tissue. Quantify retraction - helps predict need for releases and feasibility of anatomic repair. Tendon thickness <5mm suggests poor healing. Document findings systematically for operative report and medicolegal purposes

Danger Zone

Iatrogenic injury to adjacent structures

Mobilize rotator cuff - release adhesions and perform interval slides if needed: Use grasper or shaver to release bursal side adhesions, carefully releasing cuff from coracoacromial ligament, anterior acromion, posterior acromion. For retracted tears needing additional mobilization, perform anterior interval slide (release interval between supraspinatus and subscapularis) and/or posterior interval slide (release between supraspinatus and infraspinatus). Release adhesions between cuff and superior glenoid/capsule carefully staying >15mm lateral to glenoid rim to protect suprascapular nerve. Goal: tendon reaches footprint without tension

Surgeon's Tip

EXAM KEY: Adequate mobilization is critical for tension-free repair. Interval slides add 1-2cm of excursion but risk creating L-shaped or U-shaped tears if too aggressive. Anterior slide more common - release rotator interval capsule and coracohumeral ligament. Posterior slide requires careful technique near suprascapular nerve. Use traction sutures through tendon to assess mobility - should reach anatomic footprint with arm at side and minimal tension. Excessive tension increases re-tear risk. If cannot mobilize adequately, consider partial repair, margin convergence, or alternative procedures

Danger Zone

Nerve injury
Neuropraxia

Perform biceps tenotomy or tenodesis if indicated: If biceps pathologic (>50% tear, unstable, hourglass degeneration, painful), address before cuff repair. Tenotomy: release biceps at superior labrum insertion using arthroscopic scissors or radiofrequency device, allow to retract distally. Tenodesis: use interference screw, suture anchor, or soft tissue technique to fix biceps at suprapectoral or subpectoral position. Mini-open suprapectoral tenodesis common: small incision over bicipital groove, retrieve biceps, prepare bone tunnel or socket, secure with interference screw or anchor

Surgeon's Tip

EXAM KEY: Biceps decision-making important. Age >60, low demand: tenotomy acceptable. Age <60, high demand, wants cosmesis: consider tenodesis. Outcomes similar for pain relief and function but tenodesis prevents Popeye deformity and cramping. Tenodesis adds 15-20 minutes to case. SLAP repair in setting of rotator cuff tear in >40yo often fails - tenotomy/tenodesis preferred. Document decision rationale in operative note

Danger Zone

Skin necrosis from excessive tension
Damage to underlying structures

Prepare greater tuberosity footprint: Establish lateral working portal percutaneously through deltoid using Neviaser portal or standard lateral portal. Position allows perpendicular access to greater tuberosity footprint. Use motorized burr or shaver to remove remaining bursal tissue from footprint. Decorticate footprint to bleeding bone using burr - removes cortical bone exposing cancellous bone without creating trough or excessive bone removal. Create bleeding bone surface without significant structural bone loss. Mark medial extent of footprint

Surgeon's Tip

EXAM KEY: Footprint preparation enhances healing by promoting fibrovascular ingrowth. Controversy exists: some advocate minimal decortication (preserve bone stock), others aggressive decortication (maximize healing response). Evidence suggests gentle decortication to punctate bleeding bone optimal. Excessive burring creates trough which may weaken fixation or create stress riser. Footprint dimensions approximately 18mm anteroposterior by 25mm mediolateral for supraspinatus. Maintain anatomic footprint - overmedialization increases tension, overlateralization decreases contact area

Danger Zone

Iatrogenic injury to adjacent structures

Insert medial row suture anchors (for double-row or suture-bridge technique): Standard technique: double-row or suture-bridge superior to single-row (better footprint contact, biomechanically stronger, lower re-tear rates for large tears). Insert medial row anchors at articular margin-bone junction (medial footprint edge). Use 2-3 anchors depending on tear size: small tears 2 anchors, medium-large 3 anchors. Anchors typically 4.5-5.5mm knotless or knotted design. Dead-man angle (45° to bone surface) provides best pullout strength. Load anchors with high-strength suture (#2 braided polyester or UHMWPE equivalent)

Surgeon's Tip

EXAM KEY: Anchor placement at medial footprint edge optimizes force distribution and footprint coverage. Anchors placed too lateral leave medial footprint uncovered. Dead-man angle (45°) provides best resistance to pullout vs perpendicular insertion. Knotless anchors simplify technique, reduce profile, similar strength to knotted. Spacing 5-7mm between anchors. For double-row: medial row uses knotted or knotless suture anchors. For suture-bridge: medial row uses knotted mattress sutures which are then passed laterally. Know evidence: double-row shows lower re-tear rate for large tears but no functional difference vs single-row in most studies

Danger Zone

Iatrogenic injury to adjacent structures

Pass sutures through rotator cuff tendon using mattress configuration: Use suture-passing device (penetrating grasper, bird-beak, or automated device like Scorpion). Pass medial row sutures through tendon 5-10mm from edge in mattress configuration (horizontal or vertical mattress). Mattress sutures distribute load over larger area vs simple sutures. Ensure adequate tendon tissue captured - minimum 5mm depth, 10mm width. For suture-bridge technique, pass sutures through tendon but don't tie yet. For double-row, may tie medial row first or use knotless medial anchors

Surgeon's Tip

EXAM KEY: Suture-passing technique critical for avoiding re-tear. Simple sutures have higher pullout risk than mattress. Horizontal mattress (sutures parallel to tear edge) vs vertical mattress (perpendicular) both acceptable. Avoid cheese-wiring through tendon - use larger tissue bites. Ensure adequate distance from tendon edge (5-10mm minimum) to prevent pullout. Number of suture pairs: typically 2-3 pairs for medial row coverage. Modern knotless medial row anchors simplify by avoiding knot-tying

Danger Zone

Iatrogenic injury to adjacent structures

Insert lateral row anchors and complete repair (suture-bridge or double-row): Suture-bridge technique (preferred by many): medial row sutures passed through tendon and brought laterally. Insert lateral row knotless anchors at lateral footprint edge (bone-tendon junction). Pass medial row sutures into lateral anchors creating 'bridge' of tendon compressed against bone. Double-row alternative: tie medial row mattress sutures, then place lateral row simple or mattress sutures lateral to medial row. Lateral row typically 2-3 knotless anchors. Final construct: tendon bridged from medial to lateral footprint with circumferential compression

Surgeon's Tip

EXAM KEY: Suture-bridge creates superior footprint contact pressure and area vs double-row or single-row. Biomechanical studies show higher ultimate load to failure, increased contact area, improved pressure distribution. Clinical studies show lower re-tear rates for large tears. Knotless lateral fixation eliminates subacromial knot profile reducing potential impingement. Lateral row placed at lateral edge of footprint - too lateral may cause over-compression and tendon ischemia. Ensure anatomic reduction without over- or under-tensioning. Final check: tendon should cover entire footprint, no gaps, no excessive tension

Danger Zone

Iatrogenic injury to adjacent structures

Assess repair integrity and perform final checks: Use arthroscopic probe to test repair integrity - should be solid without gapping. Move arm through range of motion passively to ensure repair intact without excessive tension. Check for subacromial impingement - no prominent knots or anchors catching on acromion. Remove instruments, perform final hemostasis using radiofrequency device or arthroscopic cautery. Count instruments and sponges. Infiltrate portal sites with local anaesthetic (marcaine 0.5% with epinephrine). Remove arthroscopic fluid and close portals with nylon sutures

Surgeon's Tip

EXAM KEY: Repair should allow passive range of motion to 90° flexion, 45° external rotation without gapping or excessive tension. If excessive tension noted, may need additional releases or accept partial/medialized repair. Prominent knots can cause subacromial impingement and pain - knotless designs preferred. Post-operative imaging (X-ray or ultrasound) can confirm anchor position and no complications. Systematic operative note documentation: tear size, pattern, tissue quality, anchors used (number, size, position), suture configuration, additional procedures (biceps, acromioplasty), complications, estimated blood loss

Danger Zone

Iatrogenic injury to adjacent structures

Apply surgical dressing and immobilization: Apply sterile dressings to portal sites. Place shoulder in abduction pillow or sling with small abduction cushion (30° abduction reduces tension on repair). Avoid arm hanging dependent at side in immediate post-operative period. Provide written post-operative instructions to patient and nursing staff. Standard protocol: sling immobilization for 4-6 weeks, passive ROM only for 6 weeks, active-assisted ROM 6-12 weeks, strengthening after 12 weeks, full return to activity 4-6 months

Surgeon's Tip

EXAM KEY: Post-operative protocol balance between protecting repair and preventing stiffness. Abduction pillow reduces strain on repair especially for large tears. Controversy exists regarding immediate vs delayed passive ROM - traditional approach 4-6 week immobilization, modern accelerated protocols allow passive ROM immediately for small tears with good tissue quality. Patient factors matter: compliant patient with small tear can progress faster, non-compliant patient with large tear needs prolonged protection. Set realistic expectations: pain improves 3-6 months, strength continues improving for 12 months, final maturation up to 18-24 months

Danger Zone

Iatrogenic injury to adjacent structures

Post-operative care, rehabilitation protocol, and follow-up planning: Immediate post-op: pain control (multimodal analgesia, nerve block if available, oral analgesics), DVT prophylaxis as per protocol, physiotherapy education before discharge. Week 1-6: sling immobilization, passive ROM only (pendulum exercises, table slides, pulley-assisted forward flexion to 90°, external rotation to neutral). Week 6-12: wean from sling, progress to active-assisted ROM, isotonic strengthening initiated. Week 12-16: full active ROM, progressive strengthening (theraband, light weights). Month 4-6: return to full activities including sport/heavy labor. Follow-up: 2 weeks (wound check, initiate therapy), 6 weeks (X-ray check anchors, advance protocol), 3 months, 6 months, 12 months (final outcome assessment)

Surgeon's Tip

EXAM KEY: Rehabilitation critical for success. Re-tear risk highest in first 3 months during biological healing phase. Protection vs motion balance: excessive immobilization causes stiffness, excessive early motion risks re-tear. Evidence supports passive ROM starting immediately or week 4-6 depending on tear size and tissue quality. Active ROM delayed minimum 6 weeks. Strengthening delayed minimum 12 weeks. Return to overhead sport 6-9 months minimum. Healing on MRI/ultrasound: complete structural healing 4-6 months. Monitor for complications: infection (rare <1%), stiffness (5-10%), re-tear (10-40% depending on tear size and quality), ongoing pain requiring revision. Australian specific: Medicare item numbers, physiotherapy rebates, return to work considerations for compensation cases

Danger Zone

Nerve injury
Neuropraxia