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

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

Adequate Visualization Techniques to minimize bleeding Adequate subacromial bursectomy Subacromial decompression

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

Adequate Subacromial Bursectomy Anatomy of subacromial bursa

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

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

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

Arthroscopic Visualization Anterior subacromial bursa Posterior subacromial bursa

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

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

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

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

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

Mobilize Rotator Cuff through Marginal Convergence Sutures

Mobilize Rotator Cuff through Marginal Convergence Sutures

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.

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.

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

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

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

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

Example of Arthroscopic Rotator Cuff Repair