1. Principles of Arthroscopic Rotator Cuff Repair
Edward Tillett, M.D.
Department of Orthopedic Surgery
University of Louisville

2. Principles of Arthroscopic Rotator Cuff Repair
Adequate Visualization
Rotator cuff preparation prior to repair
Appropriate portal placement for suture passage and suture anchor placement
Secure knot tying

3. Adequate Visualization
Techniques to minimize bleeding
Adequate subacromial bursectomy
Subacromial decompression

4. Techniques to Minimize Bleeding
Adequate distension of subacromial space
Gravity inflow or arthroscopic pump
Anaesthesia to keep blood pressure normotensive or below

5. Adequate Subacromial Bursectomy
Anatomy of subacromial bursa

6. Adequate Subacromial Bursectomy
The bursectomy needs to be anterior, posterior, distal.
Must see the entire rotator cuff
Must see the insertion of the rotator cuff onto greater tuberosity
Resection: Camera and shaver must be switched between posterior and lateral portal

7. Portals for Subacromial Bursectomy
Posterior Portal:
standard posterior portal used for glenohumeral joint inspection: 2cm distal and medial to posterolateral border of acromium

8. Portals for Subacromial Bursectomy
Lateral Portal:
3 fingerbreadths distal from the anterolateral border of the acromium

9. Arthroscopic Visualization
Anterior subacromial bursa
Posterior subacromial bursa

10. Subacromial Decompression (if necessary)
Cutting Block Technique
Camera in lateral portal
Shaver in posterior portal

11. Prepare Tear for Repair
Identify type of rotator cuff tear
Mobilize tear through soft tissue releases
Mobilize tear through marginal convergence sutures

12. Identify Rotator Cuff Tear
U-shaped tear
Crescentic-shaped repair
L-shaped tear

13. Mobilize Tear through Soft Tissue Releases
Resect soft tissue above and below tear
Release of coracohumeral ligament at base of coracoid
Release of infraspinatus/supraspinatus interval in line with scapular spine

14. Mobilize Rotator Cuff through Marginal Convergence Sutures
Appropriate for U-shaped tear
Principle is to do a side to side tendon repair in an anterior to posterior direction
Lateralize the tendon towards the greater tuberosity
Take tension off the repair to the greater tuberosity

15. Mobilize Rotator Cuff through Marginal Convergence Sutures

16. Mobilize Rotator Cuff through Marginal Convergence Sutures

17. Portals for Suture Technique
Portal location is about periphery of acromium
Dependent upon the location of the tear and the type of suture retrieval device being used.

18. Technique of Suture Anchor Placement
Ideal angle of suture anchor is 45° relative to the long axis of the humerus.
Placement of suture anchor is as close to greater tuberosity as possible.
Should not repair the tendon under too much pressure, therefore, a medialized location may be necessary.

19. Technique of Suture Anchor Placement
Sometimes, the medial and lateral attachments of the rotator cuff are both repaired (double-row repair)

20. Portals for Suture Anchor Placement
Portal placement is verified with a spinal needle
The needle is directed at 45° to the humerus and close to the tendon tear where the repair is necessary

21. Portals for Suture Anchor Placement
The site of portal location varies about the rim of the anterolateral aspect of the acromium.

22. Secure Knot Tying Sliding or half hitch knots Knot Security
Loop Security

23. Example of Arthroscopic Rotator Cuff Repair