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Surgical Techniques

Arthroscopic Rotator Cuff


Repair Using Triple-Loaded
Anchors, Suture Shuttles,
and Suture Savers

Joseph P. Burns, MD
Stephen J. Snyder, MD
Mark Albritton, MD

The video that accompanies


this article is Arthroscopic
Rotator Cuff Repair, available on the Orthopaedic Knowledge
Online Website, at http://www5.aaos.
org/oko/jaaos/surgical.cfm

Dr. Burns is Associate, Shoulder


Arthroscopy Team, Southern California
Orthopedic Institute, Van Nuys, CA.
Dr. Snyder is Director, Shoulder
Arthroscopy Team, Southern California
Orthopedic Institute. Dr. Albritton is
Sports Medicine Specialist, Resurgens
Orthopaedics, Peachtree City, GA.
Dr. Burns and Dr. Albritton or the departments with which they are affiliated have
received nonincome support (such as
equipment or services), commercially
derived honoraria, or other non-researchrelated funding (such as paid
travel) from Mitek. Dr. Snyder or the department with which he is affiliated has
received royalties from and serves as a
consultant to or is an employee of
ConMed Linvatec and Arthrex.
Reprint requests: Dr. Burns, Southern
California Orthopedic Institute, 6815
Noble Avenue, Van Nuys, CA 91405.
J Am Acad Orthop Surg 2007;15:432444
Copyright 2007 by the American
Academy of Orthopaedic Surgeons.

432

rthroscopic repair has gained


popularity as the first-line technique for repairing not only smalland medium-sized rotator cuff tears,
but large and massive tears as well.
An all-arthroscopic technique is less
damaging to the overlying deltoid
muscle than are open or mini-open
techniques. In addition, an allarthroscopic technique provides
greater versatility in terms of characterizing, accessing, mobilizing, and
fixing the torn rotator cuff tendon.
Arthroscopic rotator cuff repair allows complete evaluation of the
intra-articular and bursal anatomy
while causing minimal morbidity in
terms of postoperative pain and scarring.
Because the arthroscopic technique may at first seem complex and
time-consuming, making the transition from open to arthroscopic repair
can be difficult. As with most surgical procedures, however, practice
and an organized approach can make
even many of the largest tears amenable to arthroscopic repair. We outline our stepwise technique for arthroscopic repair of full-thickness
rotator cuff tears (using triple-loaded
suture anchors) and report the key
steps necessary for maximizing efficiency and reproducibility.

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

nonsurgical management, such as


anti-inflammatory modalities as
well as strengthening of the deltoid
muscle, periscapular stabilizer muscles, and inferior intact rotator cuff
muscles. However, young patients
with traumatic rotator cuff injuries
should be considered for immediate
repair because full-thickness rotator
cuff tears do not heal or reattach on
their own and are likely to progress
to rotator cuff arthropathy. In the
middle-aged patient, the decision of
whether and when to recommend
surgery can be more difficult.
Although nonsurgical treatment
of full-thickness tears is successful
in the short-term for many patients,
long-term success is not guaranteed.
Without surgical reapproximation,
the torn rotator cuff does not heal to
bone. Additionally, the muscles undergo progressive atrophy and fatty
infiltration over time. When neglected for too long, reparable rotator cuff
tears with good tissue and favorable
prognoses can become irreparable,
with poor tissue and poor prognoses.
For these patients, an extended period of nonsurgical management may
lead to long-term complications. Active, healthy patients with symptomatic full-thickness rotator cuff
tear should be thoroughly counseled
and seriously considered for surgical
repair earlier rather than later. As
with any surgical procedure, it is
crucial to determine the needs and
goals of each patient; educate the patient about options, risks, and benefits; and tailor the treatment recommendations accordingly.

Journal of the American Academy of Orthopaedic Surgeons

Joseph P. Burns, MD, et al

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

minder in the operating room.


For most patients, we order preoperative magnetic resonance imaging scans, without contrast. A highquality magnetic resonance imaging
scan provides a great amount of information regarding the status of the
rotator cuff tendon, surrounding
muscle bellies, subscapularis and biceps tendons, AC and glenohumeral
joints, soft-tissue quality, and bone
quality. Sagittal oblique (perpendicular to the scapula), coronal oblique
(parallel to the scapula), and axial
cuts are all useful. The coronal view
often best demonstrates supraspinatus tears; the sagittal view also may
show signs of lateral tendon injury
of the supraspinatus footprint as
well as the quality and mass of the
muscle belly as it lies in the supraspinatus fossa more medially
(Figure 1). Significant fatty infiltration in the medial muscle mass may
be a poor prognostic indicator
of functional outcome, and patients
should be counseled appropriately
during the preoperative discussion.
Patient Positioning
Shoulder arthroscopy is performed with the patient in the lateral position under general anesthesia.
Lateral positioning provides easy access to all areas of the shoulder and
allows safe, low blood pressure control during anesthesia, thus minimizing bleeding and maximizing visualization. After placement of the
endotracheal tube, the patient is
carefully turned onto his or her side,
and an axillary roll is placed. In making the turn, the anesthesiologist
controls the head, the surgeon and
assistant move the torso, and the circulating nurse controls the legs. The
legs are flexed to a comfortable, balanced position and are padded, with
pillows placed between the knees
and foam pads under the dependent
ankle and peroneal nerve area. A
beanbag is used to support the torso,
with the thorax tilted approximately 20 posteriorly (Figure 2). Warm
blankets are placed over the patient,

Figure 1

Sagittal magnetic resonance image of


an atrophied supraspinatus muscle
belly (S) in the supraspinatus fossa.
The medial scapula can be seen on
either side of the supraspinatus. F =
fatty infiltration, IS = infraspinatus
muscle, SSC = subscapularis muscle,
TM = teres minor muscle

and safety straps are applied across


the torso. The table is then rotated
45 posteriorly to allow the surgeon
easy access to both sides of the
shoulder.
The shoulder is prepped and
draped. The upper limb is placed in
a sterile traction sleeve in 70 of abduction and 20 of forward flexion
under 8 to 10 lb of traction using a
shoulder traction device affixed to
the foot of the bed. A watertight seal
between the skin and the drapes is
essential. Runoff bags attached to
the drapes should be positioned to
collect both anterior and posterior
fluid. Appropriate bony landmarks
are drawn on the shoulder, including
the acromion, clavicle, AC joint, and
coracoid. An orientation line is
drawn, extending laterally from the
posterior edge of the AC joint, perpendicularly across the acromion,
and down the deltoid 4 cm (Figure 3).
This line should divide the acromion
into an anterior two fifths and a posterior three fifths. Anterior to this
line are the subacromial bursa, biceps tendon, and supraspinatus in433

Arthroscopic Rotator Cuff Repair Using Triple-Loaded Anchors, Suture Shuttles, and Suture Savers

Figure 2

Lateral patient positioning with beanbag stabilization.

Figure 3

With the patient in the lateral position, all relevant bony landmarks are marked,
including an orientation line.

sertion. Just posterior to this line are


the posterior limit of the bursal
space and the posterior bursal curtain. As surgery progresses, this orientation line is a helpful reference
for accurately creating the lateral
subacromial portal and accessing the
subacromial structures. The posterior portal position is also marked on
the skin, approximately 2 cm inferior and 1 cm medial to the posterolateral acromial corner.
The surgeon can use either a
434

gravity- or a pump-driven fluid control system. We prefer to use a pump


with which both the flow and the
pressure can be controlled.
Arthroscopic Evaluation
Arthroscopic rotator cuff repair
should begin with a standardized, reproducible arthroscopic examination of the complete intra-articular
anatomy via both the posterior and
the anterior portals. A standardized
evaluation minimizes the chance of

missing important pathology (eg,


loose bodies, subscapularis tears, superior labrum anteroposterior tears,
chondral damage) in the haste to address the rotator cuff.
A small skin incision is made,
and the arthroscope is placed in the
joint posteriorly. The joint is distended with saline via the arthroscopic pump. An inside-out technique is used to create the standard
anterior midglenoid portal: the biceps and subscapularis tendons are
visualized, and the arthroscope is advanced up against the rotator interval tissue between these two tendons. The arthroscope is then
removed from its sheath, and a
tapered-tip guide rod is passed
through the sheath and is used to
bluntly penetrate the anterior capsule, rotator interval, and anterior
deltoid until the tip can be felt subcutaneously. The tip is angled slightly superior and lateral to avoid the
coracoacromial ligament, and a
small incision is made over the palpable guide rod tip anteriorly. This
incision is usually approximately
2 cm inferior and 1 cm medial to the
anterolateral acromial edge. The
guide rod tip is passed through the
anterior incision, and an anterior
cannula is inserted over the rod and
gently worked back into the joint
until it abuts the end of the scope
sheath. Holding the position of each
cannula stable, the guide rod is removed and the arthroscope is reinserted posteriorly. Outflow is then
attached to the anterior cannula, and
a complete diagnostic examination
is performed.
A standard 15-point arthroscopic
examination is performed in all patients3 (Table 1). It is imperative that
the surgeon evaluate each shoulder
with a reproducible, consistent examination.
Surgical Preparation and
Fixation
The frayed edges of the rotator
cuff tendon on the articular side are
dbrided through the posterior and

Journal of the American Academy of Orthopaedic Surgeons

Joseph P. Burns, MD, et al

Table 1

Figure 4

Fifteen-Point Glenohumeral Anatomy Examination


Visualizing From the Posterior Portal
1. Biceps tendon and superior labrum
2. Posterior labrum and capsular recess
3. Inferior axillary recess and inferior capsular insertion on the humerus
4. Inferior labrum and glenoid articular surface
5. Supraspinatus tendon insertion
6. Posterior rotator cuff insertion and bare area on the humeral head
7. Articular surface of the humeral head
8. Anterior-superior labrum, superior and middle glenohumeral
ligaments, and subscapularis tendon
9. Anteroinferior labrum
10. Anteroinferior glenohumeral ligament
Visualizing From the Anterior Portal
11. Posterior glenoid labrum and capsule insertion into the humeral head
12. Posterior rotator cuff, including the infraspinatus and teres minor
13. Anterior glenoid labrum, inferior glenoid labrum, and inferior
glenohumeral ligament attachments to the humeral head
14. Subscapularis tendon and recess and middle glenohumeral ligament
attachment to the labrum
15. Anterior surface of the humeral head with subscapularis attachment and
biceps passage through the rotator interval

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

der excess tension. Adding up to 5 lb


more of traction may improve the
working space, as well. A complete
bursal evaluation is performed from
the anterior and posterior portals.
Viewed from the anterior portal,
the posterior bursal curtain tissue
overlying the posterior rotator cuff
video,
tendon fibers is dbrided (
2:27), as is any thickened bursal tissue laterally to improve visualization
of the cuff. This preparation becomes
useful later, once the arthroscope is
returned to the posterior portal. Although this bursal tissue may not
seem to be a problem early on, it can
become swollen and occlude visualization later in the operation.
The arthroscope is returned posteriorly, a lateral acromial portal
(LAP) is created, and the cannula is
placed. Because the LAP is the main
viewing portal during the repair, the
portal must be located in a position
that is directly in line with the center of the rotator cuff tear (Figure 4)
and at least 2.5 cm lateral from the
acromial edge. A spinal needle is

From a posterior view, the lateral portal


is established at the midpoint of the
tear.

used to assess proper portal placement before making the incision.


Selective subacromial smoothing
and a mini or complete distal clavicle resection is performed as needed,
based on preoperative radiographic
findings, patient symptoms, and
video,
the arthroscopic findings (
4:15).
Where the tendon has been torn,
the bone on the humerus adjacent to
the cartilage edge is shaved and
lightly burred; this is continued laterally for 1.5 cm over the greater tuberosity. Taking care not to injure the
undersurface deltoid muscle fibers,
the residual soft tissue on the greater
tuberosity and just enough of the cortex are removed to stimulate bleeding without excessively weakening
the bone. With good healing, this
area will supply much of the necessary blood supply. It will be covered
with new tissue as the healing cuff
edge spreads out to regenerate a footprint of attachment (Figure 5).
With the arthroscope in the LAP,
preparation of the torn edge of the
rotator cuff is completed. The thin,
feathered edge of tendon is removed
using a square-nosed biter and/or
video, 7:17).
shaver (
The tear pattern is assessed with
an arthroscopic grasper placed
through the anterior and posterior
cannulae. The pattern of the tear is
435

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.

established, tension is evaluated,


and the position of tendon repair is
planned.
Side-to-Side Rotator Cuff
Sutures
Placement of side-to-side sutures
to close the vertical component of an
L- or V-shaped tear is an important
advancement in the ability to repair
larger lesions. Side-to-side sutures
are important for two reasons: they
may help to reestablish the proper
alignment of the torn tendon ends
with their insertion site on the humerus (especially important with
L-shaped tears), and they can relieve
stress on the lateral tendon-to-bone
repair.
The single-pass side-to-side stitch
is used when the two sides of a tear
are relatively well-aligned. This
stitch is made using a crescentshaped suture hook with an absorbable monofilament suture or a permanent braided suture.
The crescent hook is inserted
through either the anterior or posterior cannula, whichever is most
direct. The hook is aligned by laying
it over the top of the tear in the direction of the desired stitch. For a Vor L-shaped tear, the first stitch
should be placed medially, near the
apex.
The needle is backed out to a
436

point 1 cm from the tear edge. The


curve of the needle is turned toward
the tendon, and the needle is driven
through it with gentle pressure, taking care not to injure the underlying
articular cartilage on the humerus.
The needle is passed through the
near side of the tear, then turned up
180 so that the curve is facing toward the acromion. The surgeon
should take care to observe the tip in
the cleft between the two sides of
the tear. The tip is advanced under
the far side of the tear and directed
through to exit 1 cm away from the
edge (Figure 6, A). An assistant stabilizes the cuff edge with a grasper
clamp during passage of the stitcher.
Excessive force may break the
stitcher tip, so firm but gentle maneuvers should be used.
A Shuttle Relay Suture (ConMed
Linvatec) is passed through the needle and retrieved out of the opposite
cannula with a grasper clamp. The
shuttle eyelet is loaded with a suture
(Figure 6, B) and carried back down
the cannula, across the tear, and out
the initial cannula (Figure 6, C). Both
suture limbs are collected from either
the anterior or posterior cannula,
based on whichever offers the best
access to the tear. The suture limbs
are tied using a sliding locking knot
(Figure 6, D).
Side-to-side stitching is repeated

as needed to close the intertendinous


defect (Figure 7). In many instances,
intertendinous defects cannot be
closed in one step. For these tears,
we often use a two-step side-to-side
stitch, in which the suture is passed
and shuttled through each side of
the tear individually. Whether such
stitches truly heal tendon tissue
back together is a matter of debate,
but side-to-side sutures are effective
in reducing both tear volume and
tension on lateral anchor-based
stitches.
Suture Anchor Fixation of
Rotator Cuff Tears to Bone:
Triple-Loaded Anchors
Triple-loaded suture anchors
maximize the strength of the
tendon-bone construct over either
double- or single-loaded anchors,
thus minimizing the risk of tendonsuture failure.4 Triple-loaded suture
anchors may allow the surgeon to
use fewer total anchors on some
tears. Suture management is slightly more complicated with this method, but with practice and careful attention to detail, it can become
routine. With three sutures, various
stitching patterns can be employed,
including three simple stitches or
two simple stitches with the third
used as a central mattress-type
stitch.

Journal of the American Academy of Orthopaedic Surgeons

Joseph P. Burns, MD, et al

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

an angle heading like that of a tent


peg under the subchondral bone
video, 11:52). With too vertical
(
an insertion angle, the anchor will
enter the softer bone of the tuberosity rather than the dense subchondral bone of the humeral head, thereby increasing the risk of anchor
pull-out failure.
Before placing the anchors, we
prefer to place pilot holeseach approximately 1 cm apart in the prepared bone bed3 to 5 mm lateral to
the articular cartilage edge. This area
corresponds to the medial extent of
the normal rotator cuff insertion; anchor placement here minimizes the
risk of overtensioning the repair by
excessively lateralizing the repair

Figure 7

Two side-to-side stitches effectively


close a large defect.
437

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

tral mattress. The least strong was


two simple sutures alone.
Three Simple-Stitch
Technique
After placing the anchor in the
bone (Figure 8, A), the surgeon
should pull with gentle tension on
the suture ends; their orientation
within the eyelet can be appreciated
just below the surface of the bone
video, 12:39). The posterior,
(
middle, and anterior sutures must be
defined, as must which suture limbs
exit the eyelet on the cuff/medial
side and which exit on the
tuberosity/lateral side. Gentle seesawing of the suture ends aids in setting the sutures in organized positions within the eyelet.
Using a loop grasper or crochet
hook, the most posterior cuff-side
suture is retrieved from the anterior
cannula, taking care to stay medial
to the remaining suture strands (Figure 8, B). This suture strand will be
passed up through the cuff as the
first simple stitch in a posterior-toanterior progression.
For stitching through the tendon,
the surgeon should use a suture
hook that affords the best angle for
passage through the cuff via the posterior portal. The first, most posterior pass often is best achieved with a
crescent-shaped stitcher. The stitcher is passed through the cuff from
top to bottom, approximately 8 mm
posterior to the anchor and 1 cm medial to the free edge. The surgeon
should visualize the needle tip exiting the bottom of the cuff end and
feed the suture shuttle through it 1
to 2 in (Figure 8, C).
Passing medial to the remaining
sutures in the anchor, the shuttle
end is retrieved with a grasper and
carried out of the anterior cannula,
where the anchor suture strand already lies. For ease of suture management, the suture strand, suture
shuttle, and grasper must follow the
same path behind the other sutures.
This will prevent entangling a passing suture with a so-called bystand-

er suture that has yet to be used.


The shuttle is loaded with the suture outside the anterior cannula
(Figure 6, B) and is carried back
through the cuff from bottom to top,
then out the posterior portal (Figure
8, D). The suture is removed from
the shuttle eyelet, and its partner
limb (tuberosity-side suture) is received out of the posterior cannula
(Figure 8, E). Both posterior limbs
will then be together within the posterior cannula in a simple stitch formation through the cuff. They are
not tied until all other sutures have
been passed. Tying the suture at this
point restricts cuff mobility and
makes it more difficult to pass subsequent stitches.
To begin the suture saving provideo, 13:38), a switching
cess (
stick is placed in the posterior cannula to hold its position, and the
cannula is backed out of the skin
over the switching stick. The sutures are removed from inside the
cannula, and the pair is loaded into a
Suture Saver (ConMed Linvatec).
The Suture Saver is a thin straw-like
tube that holds both ends of the suture together, protected and organized within its cannula. A clamp is
placed at the end of the Suture Saver outside the shoulder to hold it in
place. Then the cannula is replaced
back over the switching stick into
the subacromial space, with the suture strands stored together outside
the cannula but inside the Suture
Saver. At the end of this process, one
set of sutures is passed and is safely
protected from entanglement within
the Suture Saver (Figure 8, F).
Next, the middle suture strand is
retrieved from the anchor. The
strand that exits the anchor closest
to the cuff edge is brought out of the
video,
anterior cannula as before (
14:38). A suture hook is inserted
again and passed through the cuff
from top to bottom in line with the
middle of the anchor and approximately 1 cm medial to the cuff edge
(Figure 8, G). The shuttle is advanced through the suture hook tip

Journal of the American Academy of Orthopaedic Surgeons

Joseph P. Burns, MD, et al

and carried out the anterior cannula.


The suture is loaded and carried
back through the cuff, as was done
with the posterior suture (Figure 8,
H). The middle suture partner
(tuberosity-side) strand is retrieved;
both strands are placed together in a
Suture Saver outside the posterior
cannula (Figure 8, I). The third, most
anterior suture strand on the cuff
side of the eyelet is retrieved, and
the stitcher and shuttle are passed
and then shuttled back through the
tendon, approximately 8 mm anterior to the anchor. These sutures
should be placed in a Suture Saver if
additional anchors/stitches are to be
placed (Figure 8, J).
The subsequent anchor or anchors
are inserted anterior to the first, and
the best portal (anterior or posterior)
is determined for passage of each suture. The cuff is stitched as described
above, and each set of paired strands
is placed into savers. As the repair
progresses, each pair of sutures is held
firmly and safely in Suture Savers,
creating an organized collection of
savers (Figure 9, A) and avoiding suture entanglement (Figure 9, B).
Two Simple Sutures With a
Central Mattress Technique
Using steps nearly identical to the
three simple-stitch technique, the
surgeon can make two simple sutures as well as a central mattress
with only two passes of the stitcher.
Both cuff-side strands are retrieved
from the posterior and middle sutures in the eyelet and are brought
out of the anterior cannula. For
stitching, the surgeon should choose
the suture hook that affords the best
angle for passage through the cuff via
the posterior portal. The hook is
passed through the cuff from top to
bottom, approximately 8 mm posterior to the anchor and 1 cm medial
to the free edge of the tendon. The
surgeon should visualize the needle
tip exiting the bottom of the cuff end
and feed 1 to 2 in of suture shuttle
through.
Approaching medial to the rest of
Volume 15, Number 7, July 2007

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,

the posterior and anterior suture


pairs are tied to form a simple stitch
pattern. The middle suture pairs are
tied, forming a mattress pattern.
Securing the Rotator Cuff
After placing all sutures through
the cuff from posterior to anterior
and subsequent storage of each pair
within Suture Savers, each suture is
then tied sequentially back from anvideo, 18:54).
terior to posterior (
We prefer to use SMC (Samsung
Medical Center) sliding locking
knots5 backed up with three
alternating-post half-hitches. To tie
sutures in direct line with their passage through the anchor eyelet, tying
is performed through the lateral portal while visualizing with the arthroscope in the anterior portal. Each suture pair is easily identified in its
respective Suture Saver, removed
out the tying cannula, and tied without risk of complicated tangling.
After all sutures are tied, the cuff
edge is visualized and palpated to ensure that it is stable (Figure 10, A).
The surgeon may also replace the arthroscope into the glenohumeral
joint to evaluate the undersurface of
the repair (Figure 10, B). The portals
are closed using a single absorbable
subcutaneous suture and Steri-Strips
(3M, St. Paul, MN).
Postoperative dressing is applied.
ProWick ColdWrap dressing (Redyns
Medical, Los Angeles, CA) provides
ultra-absorbent, compressive coverage, drawing fluid away from the incision sites and into the dressing.
Cold therapy is effective with the
low-profile ProWick; this dressing is
secured with a gentle compressive
wrap rather than with skin tape, allowing easy removal without pain or
skin irritation (Figure 11). After the
dressing is applied, the arm is supported in a sling with a neutral abduction pillow.

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

Journal of the American Academy of Orthopaedic Surgeons

Joseph P. Burns, MD, et al

Figure 8 (continued)

G-J, This process is repeated for each subsequent suture in


the triple-loaded anchor. K, A completed repair with two sideto-side sutures and three triple-loaded anchors.

tral rotation sling for approximately


4 weeks. The amount of time required in the sling depends on the severity of the tear, the quality of the
cuff and bone tissue, and the security of the repair. On the day of surgery, the patient begins exercises, including squeezing a small rubber
ball and performing active elbow,
Volume 15, Number 7, July 2007

wrist, and hand movements. Shoulder shrugs and scapular adduction


exercises are begun on the first postoperative day. The incisions are kept
dry for 10 days; showers are allowed
as long as the wounds are covered
with waterproof plastic wrap. Anteroposterior and outlet radiographs
are obtained during the first postop-

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.

Postoperative application of the


ProWick ColdWrap dressing (Arthrex,
Naples, FL). This dressing has no skin
tape and can be easily removed from
the patient without irritation.

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.

physical therapy for passive range of


motion begins at 4 weeks, and aquatherapy is offered as well. Activeassisted elevation with a pulley is
begun at 6 weeks. Resisted exercises
for the cuff and scapula are added
progressively after 8 weeks as symptoms allow. At 3 months, most usual daily activities are allowed, but
the patient should not engage in any
strenuous work or sports requiring
heavy lifting, nor make quick movements. Although the tendon should
be fairly well healed to bone with
Sharpeys fibers by 3 months, it may
take at least 1 year for the muscles to
regain substantial strength.
442

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

postoperatively. No patient regretted


having had the operation.
A Southern California Orthopedic Institute study currently submitted for publication found that 37 patients younger than age 50 years who
underwent arthroscopic rotator cuff
repair achieved a mean postoperative UCLA score of 32.3 out of 35 at
a mean 5.8-year follow-up. These patients had significant improvements
in pain and strength postoperatively,
and no patient had required revision
repair at time of follow-up.7 These
results are superior to those
achieved in other studies in which
younger patients were treated with
an open technique.8-10
Most other published studies suggest that the short- and mid-term results of all-arthroscopic repairs are
statistically similar to those of open
and mini-open techniques.11-14 Others suggest that diminished pain,
motion, and even strength may be
better in arthroscopically treated
tears.15-17 Long-term outcome studies are needed. Because some question remains as to which repair technique is superior, we recommend
that each surgeon use the technique
with which he or she feels most
comfortable.

Journal of the American Academy of Orthopaedic Surgeons

Joseph P. Burns, MD, et al

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

Arthroscopic repair of rotator cuff


tears is an effective and straightforward technique when performed in
an organized, well-considered manner. We carefully developed our technique over many years, but it is not
the only one capable of achieving excellent results. We encourage anyone
interested in making the transition to
arthroscopy to practice his or her
technique outside the operating
room on shoulder models or cadaveric specimens. With practice and experience, the numerous, seemingly
complex steps can be learned and logically understood. The surgeon can
identify and correct suture management pitfalls, learn dexterity with
the instruments, perfect knot-tying,
and develop a general comfort level
with the anatomy. These skills,
learned and perfected outside the operating room, will significantly reduce the number of disruptions that
can occur inside the operating room.

Citation numbers printed in bold


type indicate references published
within the past 5 years.

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1.

2.

3.

4.

5.

6.

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Arthroscopic Rotator Cuff Repair Using Triple-Loaded Anchors, Suture Shuttles, and Suture Savers
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Journal of the American Academy of Orthopaedic Surgeons

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