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Arthroscopic Rotator Cuff Repair: Double-Row Surgical Techniques


Introduction

Rotator cuff tears are among the most common disorders affecting the upper extremity, particularly in patients over age 50. They may manifest with pain, weakness, or disability and can be extremely debilitating in active individuals. The goals of treatment are to restore strength and function with resolution of pain. Although nonoperative treatment may be beneficial in selected patients, surgery is often indicated in order to restore strength and function. Newer repair techniques, such as those involving double-row configurations, may offer improved biology and anatomic reduction of the tendon to the tuberosity footprint.

Procedure

Double-row rotator cuff repair requires adequate debridement and preparation of the host footprint on the greater tuberosity. A medial row of anchors provides initial reduction to the tuberosity. The sutures are then passed (with or without knot tying) through a second, lateralized anchor, in order to restore the anatomic rotator cuff/footprint relationship.

Patient History

  • Chief complaints (weakness versus pain versus disability) and limitations.

  • Age and baseline activity level.

  • Injury history (traumatic, recurrent, prior treatments, surgeries).

  • Present and past medical history (diabetes, cardiac, comorbidities precluding ability to undergo surgery, etc.).

  • Smoking status.

Patient Examination

  • Visual inspection (prior incisions, muscle atrophy, biceps deformity, scapular dyskinesis).

  • Palpation (tenderness over acromioclavicular [AC] joint, sternoclavicular [SC] joint, biceps/groove, tuberosity).

  • Range of motion testing: must differentiate painful restrictions from “true” restrictions (i.e., stiffness). Test both external rotation (ER) at side and abduction-rotation

  • Impingement signs (Neer, Hawkin, Jobe).

  • Rotator cuff strength/lag signs (supraspinatus: empty can or Jobe sign, infraspinatus: ER strength, ER lag sign; teres minor: ER strength in abduction, hornblower’s sign; subscapularis: internal rotation (IR) strength testing, lift-off/belly-press, IR lag, and excessive passive ER).

  • Biceps/labrum/AC: biceps signs (tenderness in groove/tendon, Speed, Yergason), labrum (O’Brien deep in joint), AC (cross body, O’Brien sign at AC).

Imaging

  • True/Grashey anteroposterior (AP) x-ray (degenerative disease, proximal humeral migration, AC joint degenerative joint disease (DJD), cystic changes in tuberosity).

  • Axillary x-ray (joint alignment, os acromiale).

  • Outlet/scapular Y-view (acromial morphology, calcific tendinitis).

  • Magnetic resonance imaging (MRI) scan noncontrast (rotator cuff tendon integrity, muscle atrophy/degeneration, edema in AC joint, integrity of biceps).

  • Compare tendon integrity on orthogonal views.

Treatment Options: Nonoperative and Operative

  • Nonoperative: rest, anti-inflammatories, physical therapy, injection.

  • Operative: several options exist in order to treat underlying symptoms:

    • Rotator cuff repair

    • Biceps tenotomy/tenodesis

    • Subacromial decompression/acromioplasty

    • Tendon transfer (latissimus dorsi tendon transfer for large posterior tears with intact anterior cuff)

    • Reverse total shoulder arthroplasty (for failed/chronic massive rotator cuff tear)

Surgical Anatomy

  • Surface anatomy: acromion, AC joint, clavicle, coracoid, coracoacromial (CA) ligament ( Fig. 20.1 ).

    FIG. 20.1, Surface anatomy and marking for shoulder arthroscopy. It is our practice to mark out the spine of the scapula leading to the acromion process (A) , along with the acromioclavicular joint (solid line) , as well as the outline of the clavicle (C) . The coracoid (Co) is marked as a reference landmark for anterior portal placement.

  • Intraarticular anatomy: rotator interval, biceps tendon, superior labrum, biceps anchor, subscapularis tendon, humeral head, glenoid, axillary pouch, posterior labrum ( Fig. 20.2 ).

    FIG. 20.2, Intraarticular view of the glenohumeral joint containing the biceps tendon (A) , rotator interval (B) , subscapularis (C) , and the humeral head (D) .

  • Subacromial space: rotator cuff tendon, acromion ( Fig. 20.3 ).

    FIG. 20.3, Subacromial view of shoulder: the rotator cuff tear is visualized from the subacromial space.

Surgical Indications

  • Full-thickness rotator cuff tear refractory to nonoperative management.

  • Acute full-thickness tear following trauma (e.g., shoulder dislocation).

  • Full-thickness tear in young active individuals with significant functional deficit.

Surgical Technique Setup

Positioning

  • Can be in beach chair or lateral position (authors’ preferred technique is beach chair, Fig. 20.4 ).

    FIG. 20.4, Beach chair setup for arthroscopic rotator cuff repair. The arm must be padded over all bony prominences, and we recommend securing it in a commercial arm holder. The patient is angled so that the surgeon has easy access to the anterior and posterior shoulder, with the arthroscopic monitor across from the surgeon on the other side of the patient.

  • Mark relevant bony landmarks: acromion (posterolateral and anterolateral corners), coracoid, AC joint, clavicle.

  • Stabilize neck in neutral position.

  • Keep bony prominences well padded (particularly with arm holders).

  • Make sure to adequately prep the surgical field (prep far medially).

  • Consider occlusive dressing around axilla/axillary hair.

Possible Pearls

  • Do a comprehensive exam in the preoperative area before block is administered. This will enable assessment of the AC joint and biceps.

  • If planning an AC joint resection, plan your anterior portal slightly superior than you normally would and place it in line with the AC joint. This will allow for easier and more direct access to joint for resection/debridement.

  • Mark incisions and portal sites before you begin surgery so that swelling does not distort anatomy and reference points.

  • Place subacromial portals in a slightly distal position to allow for subsequent swelling.

  • Ensure that head and neck are in acceptable positions and are without any stress; make sure that both are well secured and padded.

  • Double-check to make sure all equipment is in the room and ready, along with any equipment that may be necessary according to findings from arthroscopic exam (e.g., biceps tenodesis kits, appropriate anchors and suture passers, etc.).

Possible Pitfalls

  • Incomplete physical exam (especially with regards to AC joint and biceps tendon symptomatology).

  • Mark landmarks and portal locations before you start; otherwise swelling will distort the anatomy.

  • Incorrect portal placement (this will create additional difficulty throughout the case).

  • Inadequate patient positioning (i.e., not properly secured in arm holder/traction device).

  • Inadequate draping of the field (i.e., too laterally draped, therefore precluding proper AC joint debridement).

  • Not having all necessary equipment in the room prior to commencement of the case (i.e., biceps tenodesis equipment, necessary suture anchors and passers, etc.).

Equipment

  • Arm holder/traction device.

  • Full array of arthroscopic instruments (suture grasper, tissue grasper, penetrating suture grasper), along with a radiofrequency cautery device, small and large full-radius resectors for soft-tissue debridement, as well as an arthroscopic burr as needed for acromioplasty/tuberosity preparation.

  • Desired suture anchors for medial- and lateral-row suture anchors.

  • Biceps tenodesis equipment (suture for whip-stitch, along with fixation equipment, Fig. 20.5 ).

    FIG. 20.5, Equipment needed for double-row repair with possible biceps tenodesis.

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