Atlas of Advanced Shoulder Arthroscopy

Andreas B. Imhoff, Jonathan B. Ticker, Augustus D. Mazzocca, Andreas Voss, Andreas B. Imhoff, Jonathan B. Ticker, Augustus D. Mazzocca, Andreas Voss

• Publisher: CRC Press
• Year: 2017
• Print ISBN: 9780367337643
• eBook ISBN: 9781351372756
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Arthroscopic surgery has been one of the biggest Orthopedic advances in the last century. It affects people of all ages. Total joint replacement may capture popular imagination, but arthroscopy continues to have a greater effect on more people. This Atlas provides the most up to date resource of advanced arthroscopic techniques, as well as including all the standard procedures. Beautifully illustrated and supported by online videos of the latest techniques, this Atlas will appeal to both experienced shoulder surgeons as well as the orthopedic surgeon seeking to enhance his or her knowledge of shoulder arthroscopy.

SECTION III

Rotator Cuff Pathology

17

Single-row rotator cuff repair

Carl K. Schillhammer and Dan Guttmann

Contents

Introduction

Surgical principles of single row rotator cuff repair

Approaching small full-thickness and partial-thickness rotator cuff tears

Approaching medium and large rotator cuff tears

Approaching massive, retracted rotator cuff tears

Surgical technique

Initial arthroscopy and preparation

Single-row fixation for small tears

Single-row fixation for medium and large tears

Single-row fixation for massive, retracted tears

Postoperative protocol

References

Introduction

A variety of rotator cuff repair techniques have been shown to effectively improve patient shoulder function. Initially, rotator cuff repair was performed using open techniques, which involved suturing the tendon edges and fixing them back to the greater tuberosity via bony tunnels.1,2 Further development of arthroscopic equipment and technique has allowed the vast majority of rotator cuff tears to be treated via arthroscopy, allowing for smaller incisions, along with the potential for less deltoid scarring and earlier recovery.3–5

Within the context of arthroscopic rotator cuff repair, there are numerous well-described techniques, but most can be grouped into either single- or double-row methods. Biomechanics studies have shown improved footprint compression and repair durability with transosseous double-row repair.6–8 However, specific single-row techniques have shown equal and in some cases improved ability to resist tendon retraction and stretch with repetitive loading relative to double-row techniques.9,10 Clinical evidence does not clearly support one technique over the other.11–13 While some studies show decreased re-tear rates when employing double-row techniques for large tears, other studies show equal or superior results with single-row repair even in larger, degenerative tears.14

Regardless of a surgeon’s preferred technique, patient selection remains paramount. Patients with small full-thickness tears or partial tears may improve with non-operative management, including anti-inflammatory medications, corticosteroid injection, and physical therapy. However, evidence supports surgical treatment of rotator cuff tears that involve over fifty percent of tendon thickness with either a bursal or articular sided tear, especially in patients who have failed non-operative management.15–19

The authors tend to be more aggressive and offer surgery initially to patients with medium to large full thickness rotator cuff tears in younger, more active patients who do not have arthritis. It is important to keep in mind factors that can negatively affect the results of rotator cuff repair, such as advancing age (over 70), poor tendon quality, muscle atrophy with fatty changes, and history of tobacco use when assessing a patient for surgery.20–25 One should consider arthroplasty instead of arthroscopic rotator cuff repair in patients who are older and have significant arthritis and/or large retracted tears with poor quality remaining cuff tissue and superior migration, based on pre-operative X-rays and magnetic resonance imaging (MRI). For patients who are appropriate candidates for rotator cuff repair, the variety of available single-row techniques allows the surgeon incredible flexibility to address the vast majority of rotator cuff tears.

Surgical principles of single row rotator cuff repair

Approaching small full-thickness and partial-thickness rotator cuff tears

For full-thickness tears that involve up to 5 mm of the footprint, several single-row repair techniques can be effective. Small rotator cuff tears are not fraught with the issues of tendon retraction and chronic tendon shortening and degeneration. Thus, a single row construct can provide adequate tissue fixation and compression of the rotator cuff to the area of exposed tuberosity.

There are multiple approaches to repair of partial-thickness tears using single row fixation. For partial articular sided tears, the surgeon may choose to either complete the tear and then perform rotator cuff repair as in a full-thickness tear or perform a trans-tendon repair, leaving the bursal side intact. A pulley-bridge technique is an example of a trans-tendon repair option. Both techniques are effective, although pulley-bridge technique may have a slightly higher risk of postoperative stiffness.18,26

A similar approach can be taken with partial-thickness bursal-sided tears, with some surgeons choosing to complete the tear prior to fixation and others leaving the intact articular portion in place and addressing only the torn bursal tissue.15,19

Approaching medium and large rotator cuff tears

As previously discussed, there has been significant debate as to the merits of single- versus double-row repair of medium and large tears, with basic science and clinical evidence to support either technique. Basic science studies suggest that the fixation capabilities of single-row repair can vary based on suture configuration, with mattress and “Mason–Allen” type sutures performing better than simple suture techniques.27,28 Clearly, knot security is also paramount, which may be affected by the type of knot and suture material. A simple suture may be less likely to weaken the tendon-suture interface with use of a sliding knot while high molecular weight polyethylene suture allows for stronger knots than polydioax...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• Preface
• Editors
• Contributors
• Section I: Basics of Shoulder Arthroscopy
• Section II: Glenohumeral Instability and Bony Defects
• Section III: Rotator Cuff Pathology
• Section IV: Proximal Biceps Pathology
• Section V: Fractures and Chondral Defects
• Section VI: AC and SC Joint
• Section VII: Specialized Arthroscopic Techniques
• Index