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    Arthroscopic Repair of a Full-Thickness Rotator Cuff Tear

    A middle-aged male presents with persistent shoulder pain after lifting heavy boxes. MRI reveals a full-thickness supraspinatus rotator cuff tear.

    Authors

    Daniel Huttman, MD, and Mark Lazarus, MD

    Disclosures

    The authors have no disclosures relevant to this article.

    Case Presentation

    A 49-year-old male presented with a chief complaint of right shoulder pain. He had injured the shoulder 3 months earlier while lifting heavy boxes.

    He has taken anti-inflammatory medications without relief of symptoms. Two months of physical therapy had also not resolved the symptoms.

    He has a history of hypertension; he does not smoke.

    Physical Examination

    • Pain and weakness on supraspinatus testing of the affected shoulder
    • Other cuff signs negative
    • Full passive range of motion

    Imaging

    • MRI showing full-thickness supraspinatus rotator cuff tear (Figure 1)


    Figure 1. MRI of right shoulder.

    Diagnosis

    • Full-thickness rotator cuff tear

    Treatment

    Arthroscopic rotator cuff repair using a Tornier ArthroTunneler was recommended. Advantages of this procedure include:

    • Allows for arthroscopic transosseous double-row repair
    • Allows the tendon to be fixed directly to bone
    • No implants are needed
    • Costs are kept low
    • Compatible with MRI

    There are disadvantages as well:

    • Technical learning curve
    • Risks of surgery/anesthesia
    • Risk of re-tear
    • Dependent on patient’s bone quality (risk with smoker’s/osteoporosis)

    Procedure

    • The patient received general anesthesia with a preoperative interscalene nerve block. He was placed in a standard beach chair position for surgery.
    • Diagnostic arthroscopy was performed through a standard posterior portal. An anterior portal was made under direct visualization in the rotator interval.
    • An obdurator was placed into the subacromial space from the posterior portal and advanced until it reached the coracoacromial ligament. The arthroscope was then placed, looking laterally.
    • A lateral portal made under direct visualization
    • The subacromial space was debrided and the rotator cuff tear was further delineated by viewing from the lateral portal.
    • The rotator cuff tear was mobilized and characterized by using a grasper through the lateral portal.
    • The footprint on the greater tuberosity was debrided and prepared with the use of a shaver and electrocautery.
    • The posterolateral viewing portal was created approximately halfway between posterior and lateral portals.
    • Using a 2.9-mm drill just lateral to the articular surface, the medial transosseous tunnels were drilled into the greater tuberosity through an accessory portal just off the lateral border of the acromion (Video 1).
    • The patient’s arm was abducted and the ArthroTunneler was introduced into the lateral portal.
    • The tip of the ArthroTunneler was passed into the medial row tunnel and the nitnol loop was deployed.
    • The lateral row tunnel was drilled through the ArthroTunneler device (Video 2).
    • This step was repeated for a second medial tunnel in an attempt to maximize the distance between the lateral tunnel holes.
    • After each tunnel was drilled, 3 sutures were shuttled through each tunnel, 2 #2 Force Fiber sutures and a #2 FiberWire.
    • The medial limbs of each suture were passed through the rotator cuff.
    • The medial limbs of the FiberWire sutures were tied together and pulled down via the lateral limbs to act as the medial row and rip-stop stitches.
    • The Force Fiber sutures were then tied down over the lateral tunnel, giving the final construct (Video 3).


    Video 1. Drilling of the medial transosseous tunnels.


    Video 2. Drilling of the lateral row tunnel.


    Video 3. Tying the Force Fiber sutures over the lateral tunnel.

    Postoperative Course

    Immediately after surgery, the patient was placed in a sling to immobilize his shoulder. The sling was to remain on at all times. Sutures were removed at the first postoperative visit 10 days after surgery.

    One month after surgery, the patient was allowed to remove the sling and begin passive stretching exercises at home. He was allowed to use his hand with his arm remaining at his side.

    The patient began a formal physical therapy program for strengthening 3 month after surgery, and 3 months later (6 months after surgery), he was released from care with good range of motion and resolution of shoulder pain.

    Author Information

    Daniel Huttman, MD, is an orthopaedic surgeon at University Orthopaedic Clinic, Atlanta, Georgia. Mark D. Lazarus, MD, is an orthopaedic surgeon specializing in shoulder and elbow surgery at The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania. At the time this article was written, Dr. Huttman was an orthopaedic surgery fellow at Thomas Jefferson University Hospitals.

    Shoulder Section Editor, Rothman Institute Grand Rounds

    Luke S. Austin