- Suture Repair:
- if cuff is not repairable, then debride the tendon edges, it remove any further source of impingement;
-
bony trough:
- classically an osteotome is used to create a 4-5 mm wide and 25 mm long in the space between greater tuberosity and articular surface;
- the trough should usually begin just lateral to the biceps tendon;
- in the study by
Boileau et al, the authors advocated abrasion of the upper surface of the greater tuberosity w/ a burr, removing all
soft tissue and cortical bone, to create a bleeding cancellous bone bed;
- references:
-
Healing of bone-tendon junction in a bone trough: a goat partial patellectomy model.
-
transosseous hole technique:
-
tendon suture technique:
- Becker suture technique:
- has been studied extensively for flexor and extensor tendon lacerations in the hand;
- in the study by Singer et al 1998, the core suture technique was the most important element in establishing both
strength and stiffness of the repair;
- repair consists of criss-crossing running suture using a double armed needle;
- sutures should be placed 0.75 cm from the cut edge of the tendon;
- as noted in the report by Howard and Greenwald 1997, the MGH tendon repair technique (crossing running
suture repair) was signficantly more resistant to gap formation than the Bunnel or the Krackow technique;
- MGH tendon repair has superior suture purchase which is probably related to superior resistance to gap formation;
- Modified Mason Allen technique:
- has been shown to be superior to simple stitch in an experimental animal model study;
- reference:
- Experimental Rotator Cuff Repair. A Preliminary Study.
C Gerber MD.
JBJS. Sep. Vol 81-A. 1999 p 1281.
-
trans-osseous holes:
- as noted by GL Caldwell et al, JBJS 1997 and Geber et al 1999., the strength to failure was greater when:
- sutures were placed at least 10 mm distal to the greater trochanter;
- sutures were tied over a bone bridge at least 10 mm in length;
- use of a plastic button in osteoporotic bone may help prevent failure at the bone suture interface;
- some authors advocate distal placement of the transosseous holes, inorder to stay well away from soft metaphyseal bone;
- reference:
- Experimental Rotator Cuff Repair. A Preliminary Study.
C Gerber MD.
JBJS. Sep. Vol 81-A. 1999 p 1281.
-
Strength of fixation with transosseous sutures in rotator cuff repair. Caldwell GL et al. J Bone Joint Surg 79A:1064 –1068,1997
-
Cyclic loading of transosseous rotator cuff repairs: tension overload as a possible cause of failure.
-
Tendon-to-Bone Pressure Distributions at a Repaired Rotator Cuff Footprint Using Transosseous Suture and Suture Anchor Fixation Techniques.
-
tying down the sutures:
- in suturing debrided edge of
rotator cuff tissue to freshened bone or reattaching
deltoid to
bleeding acromial bone edge, surgeon should passively elevate the arm while sutures are tied;
- this avoids undue tension from sutures on soft tissues & bone if sutures are placed through holes in bone;
- it also permits easy tissue approximation and avoids weakening of suture material when it is pulled taut;
-
bone anchor technique:
- suture knots need to be kept lateral to the greater tuberosity so as to avoid impingement under the acromion;
-
direction of insertion:
- insertion of anchors at a 45 deg angle to the bone surface is recommended;
- ref:
The deadman theory of suture anchors: observations along a south Texas fence line.
-
controversies - where to insert the anchor:
- references:
-
A biomechanical evaluation of suture anchors in repair of the rotator cuff.
-
Pullout Strength of Suture Anchors Used in Rotator Cuff Repair.
- References
Mini-open rotator cuff repair using a two-row fixation technique: outcomes analysis in patients with small, moderate, and large rotator cuff tears.
A biomechanical evaluation of suture anchors in repair of the rotator cuff.
The strength of surgical repairs of the rotator cuff. A biomechanical study on cadavers.
The mechanical effects of suture anchor insertion angle for rotator cuff repair.
Enveloping the tendon graft with periosteum to enhance tendon-bone healing in a bone tunnel: A biomechanical and histologic study in rabbits.
Rotator Cuff Repair. A Biomechanical Comparison of Three Techniques.
Primary fixation strength of rotator cuff repair techniques: A comparative study.
Full-thickness rotator cuff tears. A biomechanical comparison of suture versus bone anchor techniques.
Tendon-to-Bone Pressure Distributions at a Repaired Rotator Cuff Footprint Using Transosseous Suture and Suture Anchor Fixation Techniques.
Cyclic loading of anchor-based rotator cuff repairs: confirmation of the tension overload phenomenon and comparison of suture anchor fixation with transosseous fixation.
Biomechanical Evaluation of Arthroscopic Rotator Cuff Repairs: Double-Row Compared with Single-Row Fixation.
