ARTHROSCOPIC ROTATOR CUFF REPAIR T. Andrew Israel, MD Luther Midelfort Orthopaedic & Sports Medicine Center

OPERATIVE MANAGEMENT OF ROTATOR CUFF TEARS Treatment Options Treatment Principles Surgical Indications Advantages of ARCR Disadvantages of ARCR Technique for ARCR Results

TREATMENT OPTIONS ASAD/debridement without repair Open repair Mini-open repair Arthroscopic repair

TREATMENT PRINCIPLES Address associated pathology Adequate decompression Assess tear-size, retraction, pattern, tissue quality, repairability Tendon mobilization Secure repair Supervised rehabilitation program

SURGICAL INDICATIONS Pain Functional deficits Failure to respond to nonoperative care Full-thickness tear Extensive partial-thickness tear Acute injury

ADVANTAGES OF ARCR See both sides of cuff Visualize all pathology-labral tears, biceps, OA, etc. Easier releases(esp. capsule) Less pain, morbidity Smaller scars Better ROM PATIENTS WANT IT!

DISADVANTAGES OF ARCR Learning curve ? Smaller contact area with bone for healing High retear rate by ultrasound reported ? Pain from resorption of anchors Coding/reimbursement problems

TECHNIQUE FOR ARCR Define tear Mobilize tendons Prepare tuberosity Cuff reduction Place anchors Suture management Pass sutures through tear edge Knot tying

DEFINE TEAR View from anterior and from posterior Measure with probe known size Trim ragged edges but preserve tissue

MOBILIZE TENDONS Place retention sutures Release capsule Anterior interval release Posterior interval release

PREPARE TUBEROSITY Remove excrescences but preserve cortex Trim tendon stump Define footprint

MARGIN CONVERGENCE Begin cuff reduction Work medial to lateral Side to side sutures Tie knots

PLACE ANCHORS At lateral aspect of footprint Metal or biodegradable Make sure well fixed in bone

SUTURE MANAGEMENT Keep track of portals Avoid tangles Think one step ahead Move at steady pace

PASS SUTURES THROUGH TEAR EDGE Many devices available Avoid tearing tendon Line up puncture with anchor

KNOT TYING Perfect knots Flawlessly perfect knots

RESULTS Gartsman, JBJS, 1998 73 arthroscopic RCR Average age 60.7 yrs All pts followed at least 2 yrs(30 mons) 78% G/E relief of pain 90% G/E satisfaction None of the shoulders were rated G/E preop, 84% G/E @ most recent f/u

RESULTS Burkhart, Arthroscopy, 2001 59 arthroscopic RCR Average follow-up 3.5 yrs 95% G/E result regardless of tear size Rapid return overhead function(4 mons)

CASE PRESENTATION

CASE D.E. 53 male RHD farmer Left anterior shoulder pain x 2 years No prior injury or surgery Nonoperative Rx including PT, NSAIDS, injections, activity modifications, etc.

PHYSICAL EXAM Crepitus with PROM Tenderness greater tuberosity AROM 155/170, 55/75, L5/T10 3/5 power abduction & external rotation Positive impingement tests

SHOULDER ANATOMY

SURGERY

SUMMARY Much recent enthusiasm regarding complete arthroscopic rotator cuff repair For many, this newer technique may be preferable alternative to more traditional mini-open rotator cuff repair Important that basic principles of rotator cuff repair not be compromised

SUMMARY Several short-term studies demonstrate excellent results comparable with those of traditional techniques Choice of procedure based on variety of considerations, including patient expectations, pathoanatomy of the cuff, and arthroscopic skills of the surgeon