Massive Rotator Cuff Repair with Augmentation - Arthroscopic

Preoperative Patient Care
Operative Techniques

Preoperative Plan


Radiographic templating


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

Room Preparation


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


Room setup and Equipment

  • beach chair or statndard OR table for lateral decubitus position


Patient Positioning

  • lateral decubitus position
  • pad any prominences of the extremities
  • position the head and neck in neutral alignment

Scope Insertion


Outline landmarks

  • Outline the acromion, distal clavicle, coracoid process and portal placement


Place posterior portal

  • mark portal 1 to 3 cm distal and 1 to 2 cm medial to the posterior lateral tip of the acromion
  • make small skin incision
  • place blunt trocar with the arm in 15° of abduction and 30° of forward flexion
  • use lateral traction to avoid damage to the articular surface
  • place the 30° arthroscope.


Place anterior portal

  • halfway between acromioclavicular joint and the lateral aspect of the coracoid
  • pierce the anterior fibers of the deltoid and enter the joint in the interval between the supraspinatus and subscapularis


Place lateral portal

  • place laterally in line with the mid clavicle and 2 to 3 cm lateral to its lateral edge


Place posterorlateral portal

  • 1 cm distal to the posterolateral corner of the acromium


Place Nevias portal

  • superomedial portal bordered by the clavicle the acromioclavicular joint and the spine of the scapula

Diagnostic Arthroscopy and Intra-articular Debridement


Visualize the anatomy

  • articular cartridge of the humeral head and glenoid
  • labrum
  • biceps tendon
  • inferior recess
  • articular surface
  • insertion of the subscapularis, supraspinatus, infraspinatus and teres minor


Establish anterior portal

  • localize portal with an 18 gauge spinal needle placement
  • place a seven minute millimeter cannula using the outside-in technique


Debride tissues

  • place a 4.5 mm for radius shaver in anterior portal for intraarticular debridement
  • debride degenerative labral tears, synovitis and cartilage lesions

Subacromial Bursectomy +/- Acromioplasty


Move trocar

  • move the arthroscope to the subacromial space
  • slide the trocar under the acromium over the posterior rotator cuff
  • sweep under the acromium through the lateral gutter to break up adhesions


Identify the coracoacromial ligament

  • found on the anterior aspect of the subacromial space


Create a lateral working portal

  • localize portal with spinal needle through the deltoid
  • insert 8.25 mm threaded cannula into lateral portal


Perform bursectomy

  • use a 4.5 mm barrel shaped burr through the lateral portal
  • use the full radial shaver to perform a complete bursectomy
  • remove remaining bursa and soft tissue from the undersurface of the acromion with a radiofrequency ablation wand
  • examine the anterior aspect of the acromium and cc ligament for signs of impingement


Perform acromioplasty

  • partially resect the cc ligament with the ablation wand to expose the entire acromium
  • start the acromioplasty at the anterior lateral corner and remove 5 to 8 mm of bone
  • carry the resection medially to the AC joint
  • make the resection level by sweeping the burr from anterior to posterior
  • move the arthroscope to the lateral portal place and place burr in the posterior portal
  • sweep the burr from a medial to lateral direction

Capsule Incison, Tendon Preparation, and Tendon Mobilization


Insert grasper

  • insert an atraumatic grasper through the lateral subacromial portal


Assess the cuff mobility from the articular side

  • if the supraspinatus tendon mobility is poor release the superior capsule


Place instrument into the lateral portal

  • insert an arthroscopic elevator or electrosurgical cutting device through the lateral subacromial portal


Incise the capsule

  • cut the through the capsule between the cuff tendon and glenoid rim from the rotator interval anteriorly to the scapular spine posteriorly
  • if a crescent shaped tear does not reduce to bone or a longitudinal tear does not close from side to side, perform an arthroscopic interval slide
  • place the camera in the posterior intraarticular portal
  • insert a narrow basket punch into the subacromial portal through the tear in the cuff and into the joint
  • divide the interval between the anterior border of the supraspinatus and the superior capsule from lateral to medial
  • this also releases the tendon from the contracted coracohumeral ligament on the bursal side
  • with the biceps tendon intact make the release just caudad to the tendon
  • if the biceps is not intact start the release approximately at the anterosuperior pole of the glenoid


Make portal if needed

  • make a small percutaneous portal adjacent to the lateral subacromial portal
  • place a grasper and pull on the tendon laterally

Anchor Placement, Suture Passage, Definitive Knots


Footprint Preparation

  • use shaver to remove soft tissue from the greater tuberosity
  • make sure to expose the cortical bone


Place anchors

  • place 2 or 3 medial anchors at the level of the anatomic neck
  • separate each anchor by 1 to 1.5 cm
  • make small stab incisions just off the lateral border of the acromion
  • place 2 or 3 medial anchors at the level of the anatomic neck


Pass sutures

  • pass sutures from the medial row of anchors through the tendon
  • start with the most anterior anchor
  • pass both strands of one suture through the anterior aspect of the tear in a horizontal mattress manner
  • pass sutures 1 cm medial to the lateral aspect of the tear
  • pass one strand of the second suture next to the most posterior strand o of the first suture
  • repeat steps for the posterior anchor of the medial row
  • pass two strands of one suture through the posterior aspect of the tear
  • place one strand of the second suture anterior to the previously placed mattress suture and retrieve through the anterolateral portal
  • retrieve both strands of the posterior mattress stitch out of the lateral portal
  • tie arthroscopically and cut
  • tie the remaining strands that have been passed through the tendon together
  • tie oustide the shoulder through anterolateral portal
  • cut the tails and advance the knot into the shoulder
  • this is done by pulling on the opposite strands of the two sutures
  • Place a single lateral suture anchor
  • place anchor on the lateral aspect of the rotator cuff footprint on the greater tuberosity halfway between the medial anchors
  • retrieve one strand of one suture and pass it medial to the horizontal stitch between the anterior and posterior medial anchors
  • repeat step with second suture from lateral anchor


Tie knots

  • pull on the remaining medial sutures to tension the horizontal mattress stitch while the the lateral row sutures are tied
  • retrieve the remaining two strands of the medial row anchors out of the lateral portal and tie

Allograft Reinforcement of Tendon Repair (Optional)


Measure the dimensions of the graft

  • measure the size of the graft from anterior to posterior and medial to lateral dimensions
  • use a knotted suture measuring device


Prepare the graft

  • preoperatively prepare a size 0 braided suture with 6 knots
  • these should be spaced 1 cm apart
  • hold the measuring suture with a grasper on one end
  • pass the other end into a knot pusher so that the suture with its knots can easily slide back and forth through the eyelet of the knot pusher
  • most grafts require six suture points of fixation
  • space these points evenly like the odd numbers on a face of clock
  • use two suture for lateral fixation into the greater tuberosity
  • these are simple #2 braided permanent suture that are passed through the tissue with there ends tied together to prevent pullout from the graft
  • place short-tailed interference knot (STIK) sutures evenly spaced for posterior, medial, and anterior tissue fixation
  • make a midline ink mark on the lateral aspect of the graft as a reference point


Pass the sutures through the tissue


Remove the graft from the back table

  • bring the graft adjacent to the anterolateral cannula
  • clip a wet towel around the upper arm
  • place the graft on the towel


Orient the graft anatomically


Suture the graft

  • start sequential suturing posteriorly and progress medially and anteriorly
  • have an assistant select and hold the most posterior STIK suture
  • clip the grafts two lateral sutures to the towel with a hemostat and stabilize it
  • use curved suture hooks sequentially shuttle down to the four STIK sutures down the anterolateral cannula through the rotator cuff


Pass the suture hook

  • pass a suture hook starting posteriorly through and through the rotator cuff tissue
  • pass a shuttling suture out of the anterolateral cannula with a grasper
  • shuttle the free end of the corresponding posterior STIK suture through the cuff tendon and back out of the posterior cannula
  • repeat this shuttling technique progressing medially then anteriorly


Bring the graft into the shoulder

  • insert the graft through the anterolateral cannula
  • pull the slack out of all suture
  • this docks the graft at the aperture of the anterolateral cannula
  • roll the graft onto itself to facilitate passage through the cannula
  • use a push pull technique
  • as the graft is pushed down the cannula using a small thin grasper
  • pull the STIK ends of the suture from the posterior and anterior cannulas
  • once the graft is in the shoulder sequentially tighten ech suture end to unfold the graft and cover the repair site


Secure the graft

  • tie each STIK knot sequentially
  • use 2 push in suture anchors to stabilize the lateral edge of the graft over the lateral tuberosity
  • abduct the arm to the midposition of 45 degrees to access the lateral tuberosity
  • take the two limbs for the posterolateral suture into the posterior cannula
  • create a pilot hole in the anterolateral greater tuberosity
  • load the 2 anterolateral suture limbs into the push in anchor outside of the cannula
  • place the anchor through this cannula into bone
  • bring the posterior lateral suture limbs back into the anterolateral cannula

Wound Closure, Confirm Repair and Address Intraoperative Complications


Irrigation, hemostasis, and drain

  • irrigate the portals


Deep closure

  • use 3-0 biosyn for closure


Superficial closure

  • use 4-0 biosyn for skin


Dressing and immediate immobilization

  • place sling
Postoperative Patient Care
Private Note