Arthroscopic Rotator Cuff Repair

- Discussion: 
      - rotator cuff anatomy
       - etiology of RTC tears
       - how do these tears heal?
       - massive RTC
       - open rotator cuff repair
- Technique:
    - arthroscopy exposure and setup
            - inorder to avoid extrasavation, begin with fluid pressure at 35 mm, and increased pressures incrementally as necessary;
    - irrigation fluid management
    - visualization:
            - manipulation:
consider manipulation into full flexion and abduction prior to prepping to help stretch the posterior capsule;
            - anterolateral traction will impove the viewing area, and facilitate procedure;
            - posterior portal: consider placing this slightly more lateral to facilitate visualization;
            - consider slightly shifting porotals inferior since portals will migrate superiorly with shoulder infiltration and swelling;
            - allows better triangulation (than lateral portal) for approach to supraspinatus;
            - references:
                   - Subacromial internal spacer for rotator cuff tendon repair: "the balloon technique".
                   - A Simple Way to Improve Visualization and Increase Working Space in Arthroscopy: The Pull-String Technique
                   - The Accessory Posteromedial Portal Revisited: Utility for Arthroscopic Rotator Cuff Repair
- Surgical Considerations:
        - biceps tendon and slap tear
        - subacromial bursectomy
        - cuff debridement:
                         - Apoptosis Occurs Throughout the Diseased Rotator Cuff
                         - Rotator Cuff Tear Degeneration and Cell Apoptosis in Smokers Versus Nonsmokers
        - arthroscopic acromioplasty
                    - question need for acromioplasty with RTC repair; 
        - distal clavicle excision
                - references:
                    - Asymptomatic AC joint arthritis in arthroscopic rotator cuff tendon repair: a prospective randomized comparison study.
                    - Is arthroscopic distal clavicle resection necessary for patients with radiological acromioclavicular joint arthritis and rotator cuff tears? A prospective randomized comparative study.
                    - Arthroscopic distal clavicle resection in symptomatic acromioclavicular joint arthritis combined with rotator cuff tear: a prospective randomized trial.

        - capsular release for stiffness:
                    - Are delayed operations effective for patients with rotator cuff tears and concomitant stiffness? An analysis of immediate versus delayed surgery on outcomes.
                    - Clinical outcomes of rotator cuff repair with arthroscopic capsular release and manipulation for rotator cuff tear with stiffness: a matched-pair comparative study between patients with and without stiffness.

- Cuff Repair Techniques 
       - surgical goals:
              - restoration of anatomy (with no lateralization of repair and no unnecessary increase in tension of the repair);
              - any lateralization of cuff repair may cause excessive tension (increase failure) and may end up minimizing compresssion
                        against the foot print;
              - goal should be restoration of the footprint with the end of the cuff placed under compression against the bleeding footprint; 
              - suture and anchor placement should function to compress cuff against footprint, and to work to prevent cuff lateralization;
       - required steps: 
             1) assessment of cuff tear
             2) cuff mobilization (convergence repair)
             3) preparation and restoration of  the foot print
             4) core tendon repair techniques:
                     - double row and single row techniques:
- core flexor tendon repair techniques: dont forget the contributions of the hand sugeons to tendon repair; 
                     - remember that the main cause of rotator cuff repair failure is when the suture pulls through the tendon;
                     - references:
                              - Mode of failure for rotator cuff repair with suture anchors identified at revision surgery.
                              - Medial Versus Lateral Supraspinatus Tendon Properties. Implications for Double-Row Rotator Cuff Repair
                              - An arthroscopic stitch for massive rotator cuff tears: the Mac stitch
                              - Biomechanical evaluation of arthroscopic rotator cuff stitches.
             5) bone anchor insertion
                     - this step takes into consideration restoration of footprint and optimally making sure that tensioned cuff is draped over
                              anchor site;
             7) tensioning and locking of sutures
                       - sutures can be locked to anchor vs. knot tying tech
              8) biologic measures: microfracture / PRP
                       - PRP for arthroscopic repair of large to massive rotator cuff tears: a randomized, single-blind, parallel-group trial. 

- Phyiscal Therapy after RTC Repair

- Post Operative Milestones:
Temporal Evolution of MRI Findings After Arthroscopic Rotator Cuff Repair

- Complications:
      - Incidence and treatment of postoperative stiffness following arthroscopic rotator cuff repair.
      - Upper Airway Compromise by Extravasated Fluid: A Rare Complication After Arthroscopic Repair of Atrophic Cuff Tear
      - The Long-Term Outcome of Recurrent Defects After Rotator Cuff Repair.

Pearls and pitfalls: Arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair using a tension band suture technique

Open, Mini-open, and All-Arthroscopic Rotator Cuff Repair Surgery: Indications and Implications for Rehabilitation

Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness?

Repair Integrity and Functional Outcomes After Arthroscopic Suture-Bridge Rotator Cuff Repair

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, August 29, 2016 6:17 am