1. Arm Positioning and Screw Placement in Massive Rotator Cuff Tears
WILLIAM F BENNETT MD
Sarasota, Florida

2. Purpose
Illustrate Arthroscopic Techniques to Facilitate- a) identification of retracted tendons b) separation of tendon from bursae c) separation of tendon from glenoid d) mobilization of retracted tendons e) arm positioning and mobilization f) arm positioning and screw placement g) arm positioning and suture placement h) arm positioning and knot tying
Keep in mind that chronic retraction and fatty degeneration may
indicate a situation in which the cuff is not repairable

3. a) Identification of retracted tendons
Prior to repair it is important to identify all structures torn
initial visualization of tendons from glenohumeral view can help plan the repair
repair of all tendon tears without repair of coracohumeral head tears may still result in unwanted medial lateral motion of the biceps tendon

4. a) Identification of retracted tendons(contd)
In large and massive tears crescent appearance typical from glenohumeral and subacromial view
Individual tendons vary from mainly subscapularis and supraspinatus to supraspinatus and infraspinatus to subscapularis, supraspinatus and infraspinatus
Degree of retraction varies
Involvement of heads of the coracohumeral ligament vary
View from
lateral portal

6. a) Identification of retracted tendons cont’d
Infraspinatus retracts not only medially but postero-inferiorly, best visualized from subacromial space
posterior to spine of scapula
usually is scarred into the inner fascia of the deltoid muscle
very important plane between infraspinatus and posterior deltoid
often difficult to differentiate tendon from bursae from inner fascia of deltoid

8. a) Identification of retracted tendons cont’d
Supraspinatus often retracted to glenoid level
can be visualized from glenohumeral and subacromial space
anterior to spine of scapula
recognize that while a large crescent sign is present, there is usually a component of longitudinal splitting between supraspinatus and infraspinatus
while longitudinal split may not be visible often side-to-side repair is needed to achieve coverage

10. a) Identification of retracted tendons cont’d
Subscapularis tendon can vary in its involvement from partial thickness and length to full thickness and length
best visualized from glenohumeral joint with arm in flexion and internal rotation
the lateral head of the coracohumeral ligament must be disrupted to have retraction of the subscapularis tendon
IASS may be disrupted yet subscapularis appears in relative anatomic position
the subscapularis tendon is involved approximately 30% in all rotator cuff tears to some degree

11. a) Identification of retracted tendons cont’d
* IASS may be disrupted yet subscapularis appears
in relative anatomic position
* The subscapularis tendon is involved approximately
30% in all rotator cuff tears to some degree
* MRI findings are subtle but present with subscapularis
tears

13. a) Identification of retracted tendons cont’d
Biceps subluxation can occur with varying combinations of rotator cuff tendon involvement
Supraspinatus and lateral head coracohumeral ligament
Subscapularis and medial head coracohumeral ligament
Supraspinatus , subscapularis and both heads of the coracohumeral ligament constitutes complete disruption of the bicipital sheath
Thus, important to identify structures from the glenohumeral view

15. b) Separation of tendon from bursae
Posteriorly- must take judicious time to separate infraspinatus from inner fascia of posterior deltoid
technique requires placing a shaver with closed end against the tendon and under direct arthroscopic visualization sweeping the shaver downwards while applying pressure against the infraspinatus
in time there will be a space identified between the infraspinatus tendon and deltoid

16. b) Separation of tendon from bursae cont’d
Final visualization will allow one to see the insertion of the teres minor and visualize the muscle tendon junction of the infraspinatus
The separation must be taken inferiorly to a sufficient level to mobilize the entire infraspinatus as it usually is balled up and subluxed postero-inferiorly

18. b) Separation of tendon from bursae cont’d
Superiorly the supraspinatus tendon is retracted and typically retracted to the glenoid level and anterior to the spine
It is contiguous with the coracohumeral ligament and separation of the tendon from overlying bursae and fat pads will help identify both
separation of the tendon from the fat pad is essential

20. b) Separation of tendon from bursae cont’d
Anteriorly the subscapularis may or may not be retracted
Repair of partial and full thickness partial and full length tears without retraction typically require a portion of the body of the coracohumeral ligament to be resected for visualization, area of the anterior portal
Retracted tears require the same shaver technique to remove the subscapularis from the inner fascia of the anterior deltoid

21. c) Separation of tendon from glenoid
Posteriorly- the infraspinatus can be separated from the glenoid from the lateral portal with visualization from either anterior or posterior
keep in mind that the suprascapular nerve is not far away
Superiorly-hardest to mobilize any length from anterior glenoid
Anteriorly-lateral portal, plane between the coracohumeral ligament and coracohumeral ligament

23. d) Mobilization of retracted tendons
Mobilization should be maximized so as not to place the tendons under too much tension
mobilization is more than separation
often either a stay suture of a soft tissue grasper helps to mobilize the tendons to the footprint of the rotator cuff insertion
mobilization requires that all tendons be free from glenoid and from overlying structures

24. Posterior
view
Lateral
view

25. E) Arm positioning in conjunction with mobilization
Beach Chair position allows for many degrees of freedom during the repair
the use of a Mayo stand(elevation) aids in bringing the arm into abduction in order to bring the arm to the tendons rather than the tendons to the arm
With the arm at degrees of abduction the arm can be internally and externally rotated to bring the various portions of the rotator footprint to approximation with the tendons

28. E) Arm positioning in conjunction with mobilization cont’d
Abduction and external rotation facilitates approximation of infraspinatus with footprint
further abduction facilitates approximation of the supraspinatus tendon with footprint
abduction and internal rotation facilitates approximation of the sleeve of the coracohumeral ligament

31. E) Arm positioning in conjunction with mobilization cont’d
Subscapularis mobilization and repair is best done from the glenohumeral joint
Often the IASS and/or MCHL is torn
fibers often remain attached traversing to lateral bicipital sheath
shoulder flexion and internal rotation helps visualize these lesions
a soft tissue grasper through the subacromial lateral portal can be placed through the supraspinatus defect and this tissue reduced to proper footprint

32. E) Arm positioning in conjunction with mobilization cont’d
Preparation of bed of bleeding bone for IASS attachment(subscapularis) best done through superior portal with arm in flexion and internal rotation
arm position for attachment should be with the arm at side and arm held at external rotation which is equal to opposite side

33. F) Arm Positioning and Screw Placement-infraspinatus and supraspinatus
Screw should be inserted at 45 degrees to bone
arm should be closer to side to facilitate proper angle
use one 5mm corkscrew with #2 tevdek by 2 for each centimeter of tear
start from either far anterior or far posterior and work away from first screw
I use a portal directly through the skin with no cannula placed directly anterior to the lateral subacromial portal
I place all screws through same hole
Vary screw placement by movement of arm in internal and external rotation

34. F) Arm Positioning and Screw Placement-infraspinatus and supraspinatus cont’d
Posteriorly- first screw should be at insertion of teres minor
best visualization of this insertion with arm abducted degrees and in full internal rotation
However, screw placement may require that the arm be brought out of abduction to achieve “dead-man” angle

36. F) Arm Positioning and Screw Placement-infraspinatus and supraspinatus cont’d
Place all screws at once
through same skin incision
proceed anterior from posterior to anterior by externally rotating the arm in degrees of abduction
often trial reduction of all tendons is necessary with soft tissue grasper to visualize reduction

38. F) Arm Positioning and Screw Placement-subscapularis
Subscapularis screw placement is different
Screws are placed through the anterior portal with the scope in the glenohumeral joint
If retracted screws go directly into the previously prepared bed of bleeding bone
if not retracted screws go through the tendon after noting insertion site with trial reduction
screw is brought through tendon and into the joint under direct visualization and then backed out
then the arm is brought into proper external rotation and the insertion device is used to lever the subscapularis into position and the screw is advanced into the bone

40. g) Arm positioning and suture placement
Sutures nonabsorbable #2 Tevdek preferred
tendon edges debrided to viable tissue
passage with shuttle relay or disposable suture retriever
introduced through lateral portal
retrieved through anterior portal
then pass through limb and post brought through lateral portal
various combinations of Mayo stand elevation and internal and external rotation allow for proper placement of sutures through tendons

42. h) Arm positioning and knot tying
Various combinations of Mayo stand elevation and internal and external rotation of the shoulder allow for knots to be tied by bringing bone to tendon rather than having to bring tendon to footprint and hold in place
alternative is to mobilize the tendon to footprint and hold in place with soft tissue grasper or by passing a stay suture first

43. h) Arm positioning and knot tying cont’d
First knot should secure the teres minor infraspinatus junction
usually use two knots in close proximity
knot is tied with arm abducted degrees and shoulder brought into external rotation which brings the footprint to the posterior tendons
proceed from posterior to anterior by incrementally bringing the shoulder from external rotation to internal rotation-see next slide
sometimes it is easier to secure anterior and posterior margins of the “crescent” then work on the middle portion of the tear-see 2nd following slide

45. h) Arm positioning and knot tying cont’d
Side-to-side repair is facilitated by passing a free #2 Tevdek from the anterior portal through the anterior tendons across the longitudinal split and out through the infraspinatus tendon
space developed between the inner fascia of the posterior deltoid and the infraspinatus tendon will allow for the suture to be directly visualized and retrieved through the lateral portal

50. h) Arm positioning and knot tying subscapularis
Knots are retrieved through the superior portal and then brought out through anterior cannula
dual monitor helps facilitate tying by allowing the surgeon to come to the anterior part of the shoulder and tie directed posterior
remember in this position the monitor image is a mirror image and the anatomic area you are visualizing or tying will require you to move you hand 180 degrees to the opposite side of what you think

54. NOTICE HOW BICEPS NOW CAN NOT BE
PULLED MEDIALWARD AFTER REPAIR

55. Conclusions
Employment of these techniques will allow repair of large and massive rotator cuff tears that might hitherto been though not to be repairable from a technical standpoint
remember no matter how good the technique some tendons may not be mobilized
remember no matter how good the technique if significant fatty degeneration is present in the muscles affected that even if the “cable” can be attached the “engine” may never fire again
remember no matter how good the technique some tendons have undergone chondroplastic changes and despite reattachment may not heal

56. Food for Thought
Remember (Gerber) large and massive rotator tears with open techniques have about a 30% incidence of some portion of the repair not healing
patient should be informed about this and presented with possible need for staged repair or simple force couple repair
Personal arthroscopic experience(clinical exam only) using 5mm corkscrew with #2 tevdek placed one simple suture per centimeter for massive- about 30% non-healing of a portion large-about 10% non-healing of a portion