Partial Thickness Degenerative Rotator Cuff Tear Repair - Arthroscopic

Authors:

Planning

A

Simulation

1

Set-up

  • DISCLOSURE: Orthobullets does not promote any one industry product. While we use Sawbone®, FAST®, and Magnetiscope® in this learning module, many different simulation systems can be used.
  • Secure Sawbone® rotator cuff component in the mounting bracket of the FAST® module. Plug Magnetiscope® camera into a laptop USB port and mount the camera inside the steel ball bracket. Open QuickTime player under the file tab and select "new movie recording".
  • Adjust the camera so that the rotator cuff is clearly visible in the center of the screen as it would be if you were viewing it from the anterior superior portal in a patient.
  • Place two 7mm docking cannulas, one in the anterior and one in the posterior sub-acromial portals of the FAST® simulator
  • Confirm required instrumentation is present including
  • triple-loaded suture anchor
  • docking cannulas
  • crochet hook
  • arthroscopic grasper
  • suture passers
  • suture savers
  • knot pusher
  • hemostat clamps
  • knot cutting device
  • bone punch

2

Create anchor pilot holes/bone marrow vents

  • Create anchor pilot holes 1.2cm apart
  • Create 6 – 9 bone marrow vents depending on the size of the tear

3

Place posterior anchor

  • Insert triple loaded suture anchor into the posterior anchor pilot hole
  • Ensure the horizontal depth guideline on the screw driver tip is seated 2 - 3mm below the bone and the vertical guide mark is directed toward the rotator cuff

4

First cuff stitch

  • Retrieve the medial limb of the posterior suture out the anterior cannula
  • Pass the crescent shaped suture needle with a shuttle device through the posterior cannula to pierce the cuff 6mm posterior to the suture anchor
  • Retrieve the shuttle with a grasper through the anterior cannula and load the suture in the eyelet of the shuttle
  • Retrieve the partner of the first suture (green suture) and store in a suture saver outside of the posterior cannula
  • Ensure that the suture saver is positioned on the “top” of the cuff and not on the anchor side

5

Second cuff stitch

  • Retrieve the medial limb of the middle suture into the anterior cannula
  • Use a curved 45º suture hook to pass the second stitch so that it is directly in line with the anchor and 6 mm anterior to the previous stitch. Use the green suture saver a key
  • Store the middle suture pair in a yellow suture saver

6

Third cuff stitch

  • Pass the third suture 6mm anterior to the last suture. Use the yellow suture saver as a key

7

Knot tying

  • Retrieve both limbs of the final suture into the lateral cannula and tie them with a sliding-locking knot
  • Finish the knot using 3 half hitches alternating the post between each hitch
  • Retrieve the second set of sutures from the yellow suture saver and tie
  • After tying and cutting the third suture, palpate and inspect the repair
  • After passing and saving the three sutures from the first anchor, and before tying them, insert a second and a third anchor if needed and pass the sutures and store them in suture savers. After all the sutures are passed, tie them from a lateral cannula
B

Preoperative Plan

1

Radiographic and MRI evaluation

2

Perform ligamentous exam under anesthesia

3

Execute surgical walkthrough

  • describe steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

P

1

Room setup and Equipment

  • standard OR table for lateral decubitus position
Pearls
  • Beach chair or lateral decubitus position

2

Make sure tower working

  • 30° arthroscope
  • fluid pump system
  • standard arthroscopic instruments
  • suture passing devices
  • suture retrieving devices
  • knot tying devices
  • arthroscopic shavers and burrs
  • radiofrequency ablation wand
  • suture anchors

3

Patient Positioning

  • place patient in the lateral decubitus position
  • pad any prominences of the extremities
  • position the head and neck in neutral alignment
  • support the head with a foam head cradle
  • protect the eyes with tape
  • place an axillary roll under the upper chest to protect the lower shoulder and axilla
  • ensure the entire scapula is free from the edge of the table
  • support the arm with a safe traction device in the arthroscopy position with 10 pounds of traction
  • prep and drape the arm in the usual fashion for shoulder arthroscopy

Technique

D

Scope Insertion

P

1

Outline landmarks

  • Outline the acromion, distal clavicle, coracoid process and portal placement
Pearls
  • The bursal orientation line passes from the posterior edge of the AC joint, perpendicular to the lateral acromial border.
  • It marks the posterior extent of the subacromial bursa

2

Place posterior portal

  • mark portal 2 to 3cm inferior and 1 to 2cm medial to the posterior lateral tip of the acromion
  • make 4mm skin incision
  • insert the scope sheath with a taper tip trocar into the incision and enter the joint
  • use lateral traction to avoid damage to the articular surface
  • insert the 30° arthroscope into the scope sheath
Pearls
  • place portals in the appropriate sequence; posterior first, then anterior

3

Place anterior portal

  • place the tip of the scope tightly against the capsule in the rotator interval between the biceps and subscapularis
  • pass a taper tip guide rod through the scope sheath and pierce the anterior soft tissues aiming for a spot midway between the AC joint and the tip of the coracoid
  • make a small skin incision over the tip of the guide rod
  • place a 6.25mm operating cannula over the guide rod and pass it into the joint
Pearls
  • pass the scope sheath over the guide rod and outside the anterior skin before inserting the cannula to avoid trapping soft tissue between the cannula and the guide rod
E

Diagnostic Arthroscopy

P

1

Perform the first 10 points of the 15-point exam with the scope in the posterior portal

  • 1. biceps tendon and biceps anchor
  • grasp the biceps tendon laterally and pull it into the joint to evaluate the portion that is located in the biceps groove
  • if the superior labrum is loose or traumatized palpate it with a nerve hook to determine if the biceps anchor is intact
  • 2. posterior labrum and posterior capsular pouch
  • 3. inferior capsular pouch and inferior aspect of the humeral head (? osteophyte on the humeral head)
  • 4. glenoid articular cartilage
  • 5. articular surface of the rotator cuff and rotator cuff crescent
  • 6. posterior rotator cuff attachment and bare area of the humeral head (? Hill-Sachs lesion)
  • 7. humeral head weight bearing articular cartilage surface
  • 8. anterior superior labrum and rotator interval
  • 9. subscapularis tendon and middle gleno-humeral ligament
  • 10. anterior-Inferior labrum and ligaments
Pearls
  • identify the anatomy in a step-wise manner to avoid overlooking any pathology
  • consider documenting all 15 steps of anatomy with photos or video

2

Perform the final 5 points of the 15-point exam

  • insert the scope in the anterior portal
  • 11. posterior labrum and posterior inferior capsule
  • 12. posterior superior capsule and posterior rotator cuff tendon
  • 13. anterior inferior labrum and ligaments
  • 14. subscapularis tendon and subscapularis recess medial to the glenoid
  • 15. anterior surface of the humeral head and subscapularis attachment

3

Evaluate undersurface of the cuff

  • if the articular side of the cuff is torn, debride the ragged undersurface, any labral or cartilage damage, synovitis and biceps or subscapularis pathology
  • prepare the footprint of the greater tuberosity
  • it is important to remove degenerative cuff and bursal tissue from the edge of the cartilage over the tuberosity for 2.5cm
  • be very careful not to remove cortical bone just lateral to the cartilage to avoid weakening the anchor fixation site
Pearls
  • the articular side of the cuff can only be ideally evaluated and debrided at this step
F

Bursoscopy

P
P

1

Reposition the shoulder/arm into the bursal position

  • change the arm to the bursoscopy position
  • use 10-15 pounds of weight to support the arm in 10 degrees of abduction and 5 degrees of forward flexion

2

Place the scope in the subacromial bursa

  • insert an arthroscopic sheath fitted with a blunt obturator through the posterior portal and tunnel through until the posterior edge of the acromion is encountered
  • back the sheath out and redirect it to pass through the deltoid, beneath and parallel to the lateral acromial margin and through the posterior bursal curtain
  • position the scope within the "room with a view"
  • perform the diagnostic bursal evaluation
Pearls
  • when the scope is properly positioned, the distended bursal space appears as an open chamber with ample room to maneuver
Pitfalls
  • take care to avoid tunneling too close to the acromial undersurface

3

Perform bursoscopy

  • remove all hypertrophic bursa tissue that may impede visualization
  • place the scope in the anterior portal and the operating cannula in the posterior portal and shave the bursa, especially the posterior bursal curtain
Pitfalls
  • be careful not to inadvertently injure the posterior-lateral deltoid or infraspinatus fascia
G

Subacromial Decompression

P
P

1

Change the irrigant to glycine only if using a monopolar electrode

Pearls
  • glycine allows the use of lower power when using a monopolar electrode
Pitfalls
  • you must use saline or Ringers lactate if using a bipolar electrode such as an ablator

2

Create the lateral subacromial portal (50 yard line portal)

  • use a spinal needle to locate the entry point 3cm lateral to the edge of the acromion aligned with the center of the cuff tear
  • insert a 6.25mm operating cannula in this lateral portal
Pearls
  • the 50 yard line portal is ideal to afford a balanced view the steps of the operation
Pitfalls
  • if the lateral portal is too close to the edge of the acromion it will block the insertion of the anchors

3

Place the electrosurgical cautery tool in the lateral cannula and morselize the tissues under the acromion and AC joint

  • with the scope in the posterior portal, use the cautery tool in the lateral portal to morselize the soft tissues including the bursa and coracoacromial ligament from under the anterior 2/3 of the acromial bone and AC joint
Pitfalls
  • be very careful not to cut deeply into the soft tissue anterior or lateral to the acromion to avoid damage to the deltoid muscle

4

Remove debris

  • use a 5.5mm motorized shaver in the lateral portal to remove the debris
  • use the cautery tool to outline the acromion until it is well visualized
Pearls
  • ensure that you can clearly visualize the anterior and lateral bony edge to avoid leaving a spur

5

Begin the bony decompression

  • use a high speed shaver or burr to perform the bony decompression by beginning a resection of the lateral edge of the acromion removing 5-6mm from the anterior-lateral corner and extending to the mid acromial area
Pearls
  • using a 5.5mm "bone cutting" shaver on high speed works very efficiently and avoids the need to change blades and reduces cost

6

Smooth the acromial undersurface

  • smooth the entire undersurface of the anterior half of the acromion in a sloping fashion until approximately 4-8mm is removed from the anterior edge depending on the thickness of the bone and the severity of the spur
Pitfalls
  • be very careful with the burr to avoid pitting or fracture of the acromion

7

Place the scope in the lateral portal and the shaver in the posterior portal to complete the decompression

  • finish smoothing the lateral edge of the acromion
  • resect the undersurface of the acromial facet of the AC joint
Pearls
  • the tip of the shaver allows an estimation of the amount of bone to be resected

8

Evaluate and smooth the undersurface of the acromio-clavicular joint

  • smooth and gently taper the undersurface of the clavicular facet so that it does not have an abrupt step-off from the acromion
Pearls
  • the undersurface of the AC joint can cause rotator cuff impingement
Pitfalls
  • don't attempt to make the clavicle completely flush with the acromion since that will notch the bone- simply flatten the facet
H

Preparation of Tendon and Tuberosity

P
P

1

Expose and evaluate degenerative tear

  • maintain the scope in the lateral acromial portal
  • insert the shaver into both the posterior and anterior portal as needed
  • remove torn degenerative cuff tissue from the footprint of the greater tuberosity to expose the degenerative cuff tissue
Pearls
  • often it is better to change the position of the arm to slightly more abduction to better visualize the lateral extent of the degenerative tear
Pitfalls
  • be very careful when initiating the debridement and start as far lateral as possible to avoid damaging viable tendon

2

Prepare the bony bed

  • use a motorized shaver to lightly excoriate the bony bed below the resting edge of the cuff

3

Debride the edge of the cuff back to healthy tissue

  • trim just 1-2mm of the "feathered edge" of the tendon with a basket punch or shaver
  • never debride medial to the edge of the cartilage
Pearls
  • leave any articular layer of cuff tissue intact so it may be incorporated into the cuff repair
  • the thin feathered edge of the cuff contains dead cells and proapoptotic substances and should be debrided
Pitfalls
  • avoid damaging the infraspinatus tendon attachment extending from posterior on the tuberosity
I

Anchor Placement, Suture Passage and Definitive Knots

P
P

1

Position suture anchors

  • assess the proper angle for inserting the suture anchor using a spinal needle
  • position the anchor placement ~3-4cm from the edge of the articular cartilage
Pearls
  • often it is best to use separate skin punctures to insert each anchor

2

Pre-load and seat the first anchor

  • suture anchors are pre-loaded with three different colored, high strength suture strands
  • the white suture is positioned in the center and the striped, colored strands on either side
  • insert a small bone punch and create a pilot hole a few mm lateral from the edge of the cartilage
  • insert the first anchor and screw it down through the deltoid muscle
  • screw the anchor into the bone so that it is seated 3mm below the cortical surface, angling at a "tent peg" angle of 45 degrees under the subchondral bone
  • ensure the vertical guide mark is directed toward the rotator cuff and the desired direction that the sutures will pass
Pearls
  • plan on using one "triple-loaded" anchor for each 1.2cm of the tear
  • seating the anchor 3mm below the bone surface will allow bone marrow to flow out
Pitfalls
  • carefully plan the insertion angle of the anchors to avoid injury to the cartilage
  • avoid skiving or slipping of the anchor as it starts into the bone by angling it at 45 degrees

3

Pass the first suture through the cuff

  • retrieve the posterior-most limb of suture (the one exiting the anchor on the medial side) into the anterior cannula using a crochet hook
  • pass the appropriately curved suture needle via the posterior portal and then through the cuff 5mm posterior to the anchor. exiting near the suture anchor
  • use either a crescent shaped suture hook or a right or left 45 degree curved hook as needed
  • pass a suture shuttle through the needle and retrieve it using a grasping tool and carry it into the anterior cannula
  • load the suture shuttle with the suture in the anterior cannula and carry it back through the cuff from bottom to top and into the posterior cannula by pulling on the posterior tail of the shuttle
Pearls
  • coloring the end of the retrieved suture with a surgical marker pen will aid in identifying this as the "post" suture and simplify knot tying

4

Retrieve the second suture of the posterior pair into the posterior cannula and store in a suture saver

  • retrieve the second limb of the posterior suture into the posterior cannula with a crochet hook
  • remove the cannula maintaining the portal with a switching stick and take both suture limbs outside of the cannula
  • load both limbs of the suture into a suture saver, pass it down to the top of the cuff, place a clamp on the saver to hold the sutures in position and re-insert the cannula leaving the suture saver outside the cannula
Pearls
  • using suture savers will avoid twisting sutures and facilitate tying when using triple-loaded anchors
  • be sure to pass the suture saver down to the top of the cuff and not to the anchor side to avoid blocking the view of the sutures at the eyelet

5

Pass the second and third sutures

  • place a second suture 6mm anterior to the first stitch directly in line with the anchor
  • store the pair in a suture saver outside of the posterior cannula
  • pass the third suture 6mm anterior to the middle stitch, at a 30-degree angle from the suture anchor
  • a fan-shaped pattern of sutures ensures a strong hold on the cuff without compromising blood flow
Pearls
  • each suture is passed 1cm medial to the torn edge of the cuff separated by 6mm
Pitfalls
  • avoid passing the sutures too far medial thus causing tension on the repair

6

Create bone marrow vents

  • after creating the pilot hole (if additional anchors are needed) create 4-8 bone marrow vents in the tuberosity lateral to the anchor insertion position using a 1.5mm punch
  • direct the punch to perforate the bone aiming down the humeral shaft away from the anchor insertion holes
  • angle the punch to enter the tuberosity aimed toward the elbow
Pitfalls
  • be careful not to make the holes too close together

7

Insert additional anchors (one anchor for each 1.2cm of the tear) and pass sutures as needed

  • pass the remaining sutures with an appropriately curved suture needle (crescent, right or left 45 degree curved) and shuttle and store each pair in a suture saver outside the posterior cannula
  • key off the red suture saver
  • pass the most anterior suture by first removing it into the posterior cannula with a crochet hook and using a suture needle to pass the shuttle via the anterior cannula
Pearls
  • it is better to add an additional anchor if the tear is larger than 1.5cm and remove a suture if it is not needed
  • use a consistent order for the colors of the suture savers to facilitate releasing them during knot tying

8

Tie the sutures

  • move the scope to the anterior cannula to visualize the knot tying
  • unclamp the most anterior suture saver and retrieve the sutures into the lateral cannula
  • tie the sutures together using an SMC or other sliding-locking knot
  • cut the suture to leave tails that are 2mm
Pearls
  • the suture savers facilitate tying by holding both limbs of the suture near the end and thus allowing easy retrieval without risk of twisting or crossing with other sutures
Pitfalls
  • avoid having any soft tissue over the tip of the cannula when the crochet hook is inserted to retrieve the sutures

9

Assess the repair

  • move the scope to the lateral portal to view the repair
  • use a palpating probe to examine the repair and inspect the knots
  • turn the fluid pump off to observe bone marrow flow
Pearls
  • the bone marrow flow will cover the tuberosity and cuff to create a red clot resembling a "Crimson Duvet"
  • the Crimson Duvet has a meshwork of fibrinogen that anchors the stem cells to permit regeneration of the footprint
J

Wound Closure

P
P

1

Closing the portals

  • close the incisions with a single subcuticular stitch
  • use 4-0 monocryl sutures

2

Apply steristrips

3

Place dressings

  • place surgical sponges that are primed with liquid betadine solution over the incisions
  • place and wrap surgical dressings over the incision
  • cut the arm portion of the wrap to relieve pressure around the axilla and upper humerus
Pearls
  • a compression dressing that is applied avoiding tape on the skin will prevent leakage of post op fluid and help resolve the swelling
Pitfalls
  • be sure to avoid wrapping the compression strap tightly under the axilla to prevent compromise circulation to the arm

4

Place sling

  • support the patients arm in a prefitted sling in 15 degrees external rotation and slight abduction
Pearls
  • using a slight abduction and external rotation brace post op helps the patient to regain motion and reduces the stress on the cuff repair

Patient Care

K

Preoperative H & P

1

Obtain history and perform physical exam

  • history
  • age
  • gender
  • smoker
  • trauma
  • night pain
  • physical exam
  • check range of motion
  • weakness of the extremity
  • inspect for atrophy
  • identify medical co-morbidities that might impact surgical treatment

2

Perform operative consent

  • describe complications of surgery including
  • infection
  • stiffness
  • RSD
  • retear
L

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain meds
  • wound care
  • schedule follow up
  • orders and interprets basic imaging studies
  • order postoperative radiographs of the shoulder to ensure appropriate implant placement

2

outpatient PT

  • place in a sling
  • for small and medium tears
  • remove for elbow range of motion exercises three or four times today a day
  • for large tears
  • do not remove sling and no motion for 6 weeks
M

Basic Evaluation and Management of Degenerative RCT (including Postoperative Care)

1

Obtains focused history and performs physical examination

  • provocative tests
  • Neer/Hawkins
  • O'Briens
  • lag signs
  • pseudoparalysis
  • lift-off
  • belly press
  • scapular dyskinesia
  • concomitant and associated orthopaedic injuries
  • differential diagnosis and physical exam tests

2

Orders and interprets basic imaging studies

  • radiographs
  • AP
  • true AP with active shoulder abduction
  • Axillary lateral
  • Scapular Y view
  • with chronic tears sclerotic and cystic changes of the greater tuberosity are found
  • with large tears proximal humerus migration can be found on AP and true AP views
  • look for narrowing of the acromial humeral interval on AP to identify a large tear

3

Understands indications and prescribes non-operative treatment

  • physical therapy
  • stretching, rotator cuff and scapular stabilizer strengthening exercises
  • anti-inflammatory medication
  • cortisone injections in the subacromial space

4

Understands basic indications and required workup to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provide basic post op management (phases of cuff repair rehab 1-3)

  • postop: 2-3 week postoperative visit
  • wound check
  • remove sutures
  • rehabilitation for small or medium tears
  • remain in a sling for six weeks with no shoulder motion allowed
  • remove sling at 6 weeks
  • start passive and active assisted range of motion exercises including forward elevation in the scapular plane, external rotation in full abduction, pendulum and pulley exercises
  • limit internal rotation and shoulder extension
  • no lifting, pushing or overhead activity
  • rehabilitation for large tears
  • remain in sling with no motion for six weeks
  • at six weeks remove sling and lift arm to shoulder height only
  • at six weeks use shoulder CPM device to regain forward elevation in the scapular plane
  • continue CPM until three months postop
  • diagnose and management of early complications
  • 3 month postoperative visit
  • for small and medium tears start strengthening exercises
  • isometric exercises progress to isotonic exercises
  • with a stretching program throughout
  • for large tears
  • initiate passive and active motion
  • strengthening
  • return to sports and unrestricted activity at six months
  • diagnosis and management of late complications
  • 4-6 month postoperative visit
  • for small and medium tears return to sports and full unrestricted activity at 4 to 5 months
  • for large tears return to activity at 6 months
N

Advanced Evaluation and Management of complex RCT (massive or chronic tear, diagnostic challenge)

1

Performs advanced history and physical exam to makes diagnosis among differential diagnosis.

  • Can perform history to eliminate complete differential diagnosis.
  • can identify history of scapular winging, cervical radiculopathy, and other conditions that may present with shoulder pain.

2

Interpret advanced imaging studies

  • radiographs
  • proximal humeral migration on xray
  • MRI
  • tear size
  • muscle atrophy
  • labral tears
  • arthritis
  • subscapularis tears
  • evaluates both the tendon and muscle quality
  • full thickness tears show increased signal intensity at the tendon insertion on T-2 weighted images

3

Able to perform diagnostic and therapeutic injections of the shoulder (subacromial, intra-articular)

O

Evaluation and Management of RCT Complications and Revisions

1

Is able to perform a detailed history and physical exam to diagnosis cause of failure or complication.

  • modify for massive cuff repairs
  • post-operative stiffness

2

Order and interpret advanced imaging studies in order to confirm cause of failure or complication.

  • MRI
  • evaluates both the tendon and muscle quality
  • tear size
  • muscle atrophy
  • labral tears
  • arthritis
  • subscapularis tears
  • full thickness tears show increased signal intensity at the tendon insertion on T-2 weighted images

3

Able to perform invasive studies to confirm the diagnosis.

  • this includes aspirating the joint to rule out sub-clinical infection

4

Treats intra-operative and post operative complications

  • irrigation and debridement for infection
  • proper infection treatment
  • infectious disease consultation
 

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