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Arthroscopic rotator cuff repair: Single-row technique


OVERVIEW

Chapter synopsis

  • Arthroscopic repair of the rotator cuff with a single row of suture anchor fixation represents a well-established technique with a high rate of success. Single-row arthroscopic rotator cuff repair can be executed consistently and effectively with relative ease. As with any technique—open or arthroscopic—proper tear pattern recognition and mobilization are essential elements to an appropriate repair. Advantages over more recent double-row techniques include reduced implant cost and, in most cases, decreased complexity and operative time with no clear compromise of clinical outcome

Important points

  • Indicated for symptomatic patients with full-thickness tearing of the rotator cuff who have failed or are inappropriate candidates for nonoperative management

  • Triple–loaded anchors and/or tissue–grasping suture patterns can reinforce tissue security

Clinical and surgical pearls

  • Accurate identification of the tear is essential to planning and executing an appropriate repair

  • Effective mobilization of the torn tendon(s) via a variety of releases and use of adjunct repair techniques such as margin convergence facilitates performing a repair with minimal tension

Clinical and surgical pitfalls

  • Incorporation of local autograft, such as the long head of the biceps tendon into the retracted portion of the rotator cuff can facilitate tendon repair. Failure to recognize and debride scarred bursa along the leading edge of the torn rotator cuff (bursal leaders) can result in underestimation of the extent of the tear

Video available

  • : Bursal leader debridement

  • : Posterior capsular release and posterior interval slide

Controversy exists between advocates of single-row anchor fixation and those who advise use of two such rows (e.g., “double row,” “dual row,” “suture bridge,” “transosseous equivalent”). Proponents of single-row fixation cite decreased cost and decreased operative time and point out the dearth of clinical outcome studies that justify use of double-row techniques. Proponents of double-row fixation, on the other hand, cite biomechanical advantages that include superior repair strength and footprint coverage, decreased micromotion at the tendon-bone interface, and increased, more homogeneous pressure distribution across the repair site. All of these factors, they suggest, might translate into improved healing potential at the tendon-bone interface.

With respect to fixation, the use of single-row fixation remains an acceptable and in most cases a less technically challenging arthroscopic repair technique for repair of the rotator cuff. Furthermore, given certain time-tested principles of rotator cuff repair, such as minimization of tension at the repair site, larger L-shaped, reverse-L–shaped, and U-shaped tears may be better suited to a single-row approach, particularly if they are chronic or acute-on-chronic with limited mobility, as aggressive efforts toward “anatomic” footprint coverage may result in excessive repair tension. Finally, regardless of the technique used for repair, the need for recognition of tear size and pattern, execution of necessary mobilization procedures including interval slides when indicated, appropriate footprint preparation, effective suture management, and appropriate rehabilitation remain essential elements of any properly performed arthroscopic rotator cuff repair.

Preoperative considerations

History

  • Traumatic event, most commonly a fall from standing height with subsequent, temporary inability to actively abduct the arm away from the side

  • Night pain

Signs and symptoms

  • Anterolateral or direct lateral shoulder pain that may radiate down to, but rarely beyond, the elbow

  • Dull ache at rest that may become sharp with overhead or outstretched use of the involved extremity

  • Difficulty with overhead activity secondary to pain and/or “quick” fatigue

  • Difficulty with outstretched activity secondary to pain and/or quick fatigue

Physical examination

  • Observable atrophy in the supraspinatus and/or infraspinatus fossae (large or chronic tears)

  • Tenderness to palpation over the anterolateral shoulder or greater tuberosity

  • Reproducible anterolateral or lateral shoulder pain on manual motor testing of the rotator cuff

  • Weakness with manual motor testing of the rotator cuff (large or chronic tears)

  • Positive “hornblower’s sign” with massive posterolateral tears (inability to actively externally rotate with the arm supported in 90 degrees of abduction)

  • Positive bear–hug test with small and positive lift-off test with massive anterosuperior tears

Imaging

  • Plain radiographs consisting of Grashey, outlet, and axillary views for the following:

    • Evidence of greater tuberosity fracture when a history of trauma is present.

    • Acromial morphology including identification of enthesophyte on outlet view and os acromiale on axillary view.

    • Presence of static superior migration of the humeral head with respect to the glenoid. Note that the presence of such static changes together with a large or massive tear serves as a relative contraindication to operative repair. Superior static migration is the condition to look for on plain radiographs. Presence of a massive tear is inferred from the presence of observable static migration.

    • Presence of degenerative, chronic changes such as osteophyte formation along the inferior anatomic neck of the humeral head, acetabularization of the undersurface of the acromion, sclerosis and “rounding off” of the greater tuberosity, narrowing of the glenohumeral joint space, and loss of sphericity of the humeral head.

  • Magnetic resonance imaging (MRI) for the following:

    • Identification of tear size, degree of retraction, tendon quality, and presence of intratendinous delamination and potentially recognition of tear pattern ( Fig. 21.1 ).

      Fig. 21.1, Proton density, fat-saturated coronal magnetic resonance image depicting full-thickness tearing of the supraspinatus with delamination and a moderate degree of tendon retraction.

    • Quantification of associated muscle belly atrophy and fatty infiltration. Note this is best performed on T1-weighted sagittal oblique views at the first cut in which the scapular spine becomes visible and can be useful in determining the reparability of the tear.

    • Identification of associated, potentially surgical pathology such as acromioclavicular arthritis or osteolysis, partial-thickness tearing; or subluxation of the long head of the biceps tendon, articular cartilage defects, labral pathology, calcific tendonitis, intra-articular loose bodies, and subscapularis pathology.

  • Ultrasonography

    • Inexpensive alternative to MRI for soft tissue evaluation

    • Highly dependent on technical skill of ultrasonographer

    • Ability to perform dynamic evaluation

Tear size and classification

Size (anterior-to-posterior dimension)

  • Small: Up to 1 cm

  • Medium: 1 to 3 cm

  • Large: 3 to 5 cm

  • Massive: Greater than 5 cm or involving three or more tendons of the rotator cuff

Classification

  • Partial-thickness

    • Bursal-sided

    • Articular-sided

    • Intrasubstance

  • Full-thickness

    • Crescent

    • U-shaped

    • L-shaped

    • Reverse-L–shaped

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