8 Pearls for Arthroscopic Rotator Cuff Repair
Although the technology and techniques for rotator cuff repair continue to evolve and improve, the key principles of repair have not changed since they were espoused by Dr. Charles Neer:
- Repair the rotator cuff anatomically
- Provide a low-tension repair
- Have good tendon grasping with the sutures
- Ensure minimal gap formation so that the tendon can heal to bone
- Prescribe appropriate rehabilitation
To help surgeons achieve these goals, Peter J. Millett, MD, MSc, shared his top 8 tips, tricks, and techniques for successful outcomes with rotator cuff repair at ICJR’s 13th Annual Winter Hip & Knee Course.
Understand the anatomy of the rotator cuff tear and the biomechanics of the repair construct. Restoring the anatomy – in other words, restoring the muscle-tendon units that have been torn – restores function, Dr. Millett said. In addition, newer repair constructs will:
- Decrease suture cut-through
- Minimize load per unit area, decreasing the risk of a type 2 tear
- Maximize vascular inflow to the healing tendon
- Prevent over-tensioning with medial knots
- Maximize the concept of self-reinforcement
- Avoid irritation in the subacromial space
- Maximize biology, with the tapes acting as a bioscaffold for new tissue growth
Patient selection. Performing a procedure technically well in the wrong patient or for the wrong reason, will not result in a good outcome, Dr. Millett said. Factors that are predictive of the outcome include:
- Chronicity of the tear
- Tear size
- Tendon and muscle quality
- Healing potential – for example, the impact of age and comorbidities
- Associated worker’s comp claim
- Postoperative rehab potential
Correct portal placement. With the patient in the beach chair position, Dr. Millett establishes 4 portals for the rotator cuff repair: posterior, anterosuperior, anterolateral, and posterolateral. He will use additional portals as needed to assist with the trajectory, ensuring that he is inserting the anchors at the appropriate angle for a successful repair.
Preparation of the subacromial space. This includes:
- Acromioplasty as needed, which is in most cases in Dr. Millett’s experience
- Preparing the footprint to ensure a good bleeding surface for bone healing
- Releases to minimize the tension on the repair
Recognition of the tear pattern, which is crucial for an anatomic and successful rotator cuff repair. Dr. Millett recommends visualizing the tear pattern laterally to assess its 3-dimensional nature and to look for delaminations. The common tear patterns, which dictate how the tear will be repaired, are:
- Chronic L-shaped (or reverse L-shaped)
Determine the desired method of repair (fixation). As mentioned above, the repair method is dictated by the tear pattern. Fixation methods include single-row, double-row, and linked constructs. The key points to remember, Dr. Millett said, are to:
- Understand the anchors or transosseous method being used
- Understand the suture material being used
- Be flexible with the repair construct; in some cases, a combination of knotted and knotless constructs may be required
Identify and address the associated pathology. Dr. Millett said he performs a long head biceps tenodesis with most of his rotator cuff repairs. He also performs a distal clavicle excision for a symptomatic acromioclavicular joint, and occasionally he performs a labrum repair.
Prescribe the appropriate rehab. Rehabilitation is tailored to the repair. The rehab should progress slowly for a patient with a large tear and poor-quality tissue, Dr. Millett said, but can go more quickly for a patient with small- or medium-sized tear or even for a large tear with good-quality tissue and secure fixation.
Click the image above to watch Dr. Millett’s presentation and learn more about arthroscopic rotator cuff repair.
Peter J. Millett, MD, MSc, is a partner at The Steadman Clinic in Vail, Colorado, specializing in disorders of the shoulder, knee, and elbow and all sports-related injuries. He is also the Chief Medical Officer of The Steadman Philippon Research Institute.
Disclosures: Dr. Millet has disclosed that he receives royalties from and is a paid consultant for Arthrex, Inc., and MedBridge and that he has stock or stock options in GameReady.