Professional Documents
Culture Documents
Joseph P. Burns, MD
Stephen J. Snyder, MD
Mark Albritton, MD
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Indications
Standard protocol encourages a period of nonsurgical management for
rotator cuff tears. Older patients
with mild symptoms and chronic
tears are excellent candidates for
Contraindications
Contraindications to rotator cuff repair include severe osteoarthritis of
the glenohumeral joint, overriding
medical comorbidities, and activity
demands sufficiently low to tolerate
rotator cuff deficiency. For patients
with concomitant adhesive capsulitis, we prefer to rehabilitate the stiff
shoulder before performing rotator
cuff repair. Patients with failed prior
rotator cuff surgery and significant
fatty infiltration should be counseled that the outcome generally is
less predictable.
Surgical Technique
Preoperative Imaging
Preoperatively, four standard radiographic views are obtained of the
injured shoulder: true anteroposterior (perpendicular to the plane of
the scapula), lateral supraspinatus
outlet, axillary, and Zanca (acromioclavicular [AC] joint).1 Done correctly, these views give a thorough appreciation of bony anatomy. The
supraspinatus outlet view also is
used to classify and determine the
thickness of the acromion.
The acromion is classified preoperatively by shape according to the
classification of Bigliani and Morrison:2 type 1, flat acromion; type 2,
gently curved acromion; and type 3,
acromion with a sharp inferior
beak. The surgeon considering subacromial decompression or a smoothing procedure should be aware of the
amount of bone available. Acromial
thickness can vary widely. Thus, we
also classify the acromion based on
thickness: type A, <8 mm; type B, 8
to 12 mm; and type C, >12 mm.
These measurements are made on the
supraspinatus outlet view, as well,
1.5 to 2 cm behind the anterior edge
of the acromion in an area that corresponds to the posterior aspect of the
AC joint. Most of our patients have
presented with type 2B acromial
arches. We write this classification directly on the radiograph as a visual reVolume 15, Number 7, July 2007
Figure 1
Arthroscopic Rotator Cuff Repair Using Triple-Loaded Anchors, Suture Shuttles, and Suture Savers
Figure 2
Figure 3
With the patient in the lateral position, all relevant bony landmarks are marked,
including an orientation line.
Table 1
Figure 4
anterior portals, taking care to remove as much as possible of the remaining fragments of tendon from
the footprint area. Placing the
shaver above the biceps tendon usually allows better access to the tuvideo, 0:40). Switching
berosity (
the arthroscope anteriorly and the
shaver posteriorly is an especially effective technique for footprint dbridement. Undersurface dbridement from within the joint is
particularly important because it
can be difficult to visualize this
anatomy when the arthroscope is
later changed to the bursal position.
After undersurface dbridement,
the arthroscope is inserted into the
bursa through the posterior portal,
and the anterior outflow cannula is
placed through the anterior portal.
Before insertion of the arthroscope,
however, the arm traction device is
adjusted to change the arm position
to 30 of abduction and 5 of flexion.
This improves bursal visualization
and moves the arm to the side, ensuring that the repair will not be unVolume 15, Number 7, July 2007
Arthroscopic Rotator Cuff Repair Using Triple-Loaded Anchors, Suture Shuttles, and Suture Savers
Figure 5
T2-weighted serial coronal oblique magnetic resonance images demonstrating lateral expansion of the healing tissue at
4 weeks (A), 2 months (B), and 2 years (C) after arthroscopic repair to the medial supraspinatus footprint.
Figure 6
Side-to-side stitch technique. A, The tear is visualized from the lateral portal, and the crescent-shaped stitcher is passed through
the cuff. A Shuttle Relay Suture (ConMed Linvatec, Largo, FL) is passed out the opposite portal. A suture eyelet is loaded (B),
and the suture is passed back through the tendon (C). D, A sliding locking knot is tied. A = acromion, B = long head of biceps
tendon, C = clavicle, Co = coracoid, T = location of the torn tendon
Still viewing from the LAP, a spinal needle is inserted percutaneously and adjacent to the lateral acromion to determine the proper position
and angle for suture anchor placement. When the position and angle
of the spinal needle are appropriate
for anchor placement, a no. 11 blade
is used to create a small stab incision
(3 to 5 mm) in the skin. Careful positioning and planning may allow
two or three suture anchors to be
placed into the tuberosity through
the same stab incision. For larger
tears, however, two different entry
sites may be required. The posterior
anchor is inserted first. The angle of
entrance into the bone is crucial; it
must approach the humeral head at
Volume 15, Number 7, July 2007
Figure 7
Arthroscopic Rotator Cuff Repair Using Triple-Loaded Anchors, Suture Shuttles, and Suture Savers
site. A pilot hole punch (often included with the suture anchor set) is
inserted through the small stab skin
incision. The punch vectors are directed so that the posterior hole angles slightly posteriorly and the anterior hole angles slightly anteriorly.
Fanning out the holes in this way
ensures that each anchor has a solid
wall of surrounding bone.
The ThRevo (ConMed Linvatec)
triple-loaded suture anchor comes
loaded with three differently colored
braided sutures. Other brands of anchor also may allow the surgeon to
manually load a third suture into the
eyelet. The ThRevo anchor has a
vertical guide mark on the insertion
handle shaft perpendicular to the
eyelet hole, which marks the suture
alignment within the eyelet.
The first anchor is inserted
through the skin incision used for
video,
the pilot hole punch (
12:10). The posterior anchor is
placed first. It is screwed into the
bursal space through the deltoid
muscle, and the anchor tip is seated
into its pilot hole. The screw is
aligned so that it follows the direction of the pilot hole, seating into
the bone at an angle of approximately 45. The vertical guide mark must
be directed toward the cuff (ie, toward the desired direction in which
the sutures will pass). The anchor
eyelet will be parallel to the articular surface/cuff edge, and the sutures
passing through it thus will be perpendicular to the articular surface/
cuff edge.
Suturing Technique
A recent study by Coons et al4
compared the strength under repetitive loading of various stitching patterns with two and three sutures per
anchor. An anchor with three simple
sutures passed through the cuff was
the strongest construct, while two
simple sutures with a central mattress passing through the same holes
as the simple sutures was second
strongest. This was followed by two
simple sutures with a separate cen438
the sutures in the anchor, the shuttle is retrieved with a grasper and
carried out the anterior cannula. For
ease of suture management and to
avoid tangling with a bystander
strand, the suture strand, suture
shuttle, and grasper must follow the
same path medial to the other sutures. The shuttle is loaded with
both sutures outside the anterior
cannula, and both sutures are carried
back through the cuff and out the
posterior cannula. The partner limb
of the posterior suture is retrieved
only out of the posterior cannula;
the tuberosity-side partner limb of
the middle suture is left in place.
The posterior sutures are saved in a
Suture Saver. The switching stick is
placed in the posterior cannula, and
the cannula is backed out of the
skin. All three of the sutures are
then removed from inside the cannula, and the posterior pair is loaded
into a Suture Saver. With the posterior sutures in it, the Suture Saver is
clamped, and the cuff-side middle
suture alone is left outside the cannula. The cannula is replaced over
the switching stick with the three
suture limbs outside the cannula.
Both the remaining limb (tuberosity-side) of the middle suture as
well as the cuff-side limb of the anterior suture are retrieved out the anterior cannula. A suture hook is inserted a second time and passed
through the cuff from top to bottom,
this time anterior to the anchor and
approximately 1 cm medial from the
cuff edge. The shuttle is sent
through the needle and out the opposite cannula, after which both sutures are loaded into the shuttle and
carried back through the cuff and out
the posterior stitching portal. The final suture left in the anchor (the
tuberosity-side limb of the anterior
suture) is retrieved, and the anterior
suture pair and the middle suture
pair are placed in separate Suture
Savers, outside the posterior cannula, along with the posterior suture
pair that was saved in the first step.
After two passes with the stitcher,
Postoperative Care
Postoperative management consists
of protecting the cuff repair in a neu439
Arthroscopic Rotator Cuff Repair Using Triple-Loaded Anchors, Suture Shuttles, and Suture Savers
Figure 8
Three simple-stitch technique. A, The most posterior anchor is placed percutaneously, 2 to 3 mm lateral to the edge of the
humeral articular surface. B, Using a stepwise approach, the most posterior cuff-side suture is identified and taken from the
anchor eyelet out the anterior cannula with a crochet hook. C, A tendon stitcher is used to penetrate the tendon and pass a
suture shuttle (black) through the tissue, where it is grasped and brought out of the anterior cannula with the aforementioned
suture. The suture shuttle is advanced through the stitcher, across the tendon, and out the anterior cannula until its open eyelet
(used to hold the suture) is advanced out the anterior cannula. D, The end of the suture is placed through the shuttle eyelet,
and both the shuttle and the suture held within its eyelet are pulled, via the posterior cannula, back through the subacromial
space, across the tendon, and out posteriorly. The partner tuberosity-side suture is retrieved our the posterior cannula (E), and
the paired ends are placed together in a Suture Saver (ConMed Linvatec) and stored outside the cannula (F).
440
Figure 8 (continued)
erative visit to document the position of the anchors and evaluate the
subacromial decompression.
Pendulum exercises are begun after the first week. As long as the subscapularis and posterior cuff are intact, gentle isometric internal and
external exercises with the arm in
neutral rotation are added. Formal
441
Arthroscopic Rotator Cuff Repair Using Triple-Loaded Anchors, Suture Shuttles, and Suture Savers
Figure 9
Figure 11
Suture Savers (ConMed Linvatec) provide organization and protection for paired
suture ends within the shoulder before knot-tying, allowing the tendon to remain
accessible and mobile as stitching progresses. B, Without this organization, the
sutures often become entangled.
Figure 10
A, Arthroscopic image demonstrating three tied sutures, which are well spread out.
The tendon is firmly reattached to the bone. B, Intra-articular view confirming
anatomic repair.
Results
In 2002, Murray et al6 reported the
results of 45 patients with 48 medium to large cuff repairs that were
managed arthroscopically. Average
patient age was 57.6 years, and mean
follow-up was 39 months (range,
2466 months). Shoulder pain, as
rated on the UCLA shoulder index
(scale of 10), improved from 3.3 preoperatively to 9.3 at follow-up. Function improved from 5.4 to 9.5. Perhaps the most important parameter
is patient satisfaction with surgery.
On a scale of 0 to 5, this score improved from 0 preoperatively to 4.9
Pearls
The technique should be practiced outside the operating room on models, at laboratories, or at courses.
The surgeon who is comfortable with a mini-open approach can progress with the arthroscopic approach
as far as possible and then convert to mini-open (possibly after a predetermined period of time) to critique
his or her progress and technique.
Translucent cannulas should be used to maximize visualization. To accept most curved stitchers, flexible cannulas must be >6.5 mm in diameter, while stiff cannulas must be >8.0 mm. Two smooth metal
switching sticks are invaluable when moving cannulas around the shoulder.
Runoff bags should be carefully positioned to keep the patient dry.
Fluid pressure should be monitored and adjusted as needed to maximize visualization and minimize
shoulder swelling.
Complete bursectomy, especially posteriorly and laterally, should be done early in the procedure because
the bursa can swell over time and become a problem.
When grasping and shuttling sutures in and out of the shoulder, the surgeon must take care to watch the
suture in the anchor eyelet so as not to unload it (ie, pull it entirely out of the eyelet).
Suture ends should be stored in Suture Savers to prevent entanglement and to allow the cuff to stay somewhat mobile while passing subsequent stitches.
The surgeon should educate his or her assistants and cultivate their understanding of the process.
Pitfalls
Sloppy patient positioning will lead to inferior and unpredictable access to the shoulder.
The surgeon should understand the fluid management system in order to be able to troubleshoot when
problems arise.
The surgeon must not cut corners. Diligence in following the proper steps will pay off by avoiding more
time-consuming mistakes, such as suture entanglement and unloading of the anchor.
Summary
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
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Arthroscopic Rotator Cuff Repair Using Triple-Loaded Anchors, Suture Shuttles, and Suture Savers
open salvage repair of the rotator cuff
tear: Outcome analysis at 2 to 6 years
follow-up. Arthroscopy 2003;19:746754.
14. Youm T, Murray DH, Kubiak EN, Rokito AS, Zuckerman JD: Arthroscopic
versus mini-open rotator cuff repair:
A comparison of clinical outcomes
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