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

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

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

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

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

6. 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!

7. 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

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

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

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

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

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

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

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

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

16. KNOT TYING
Perfect knots
Flawlessly perfect knots

17. 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% most recent f/u

18. 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)

19. CASE PRESENTATION

20. 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.

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

29. SHOULDER ANATOMY

30. SURGERY

31. 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

32. 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