Arthroscopic Rotator Cuff Repair

Arthroscopic Rotator CuffRepair Using Triple-LoadedAnchors, Suture Shuttles,and Suture Savers

Arthroscopic repair has gainedpopularity as the first-line tech-

nique for repairing not only small-and medium-sized rotator cuff tears,but large and massive tears as well.An all-arthroscopic technique is lessdamaging to the overlying deltoidmuscle than are open or mini-opentechniques. In addition, an all-arthroscopic technique providesgreater versatility in terms of charac-terizing, accessing, mobilizing, andfixing the torn rotator cuff tendon.Arthroscopic rotator cuff repair al-lows complete evaluation of theintra-articular and bursal anatomywhile causing minimal morbidity interms of postoperative pain and scar-ring.

Because the arthroscopic tech-nique may at first seem complex andtime-consuming, making the transi-tion from open to arthroscopic repaircan be difficult. As with most surgi-cal procedures, however, practiceand an organized approach can makeeven many of the largest tears ame-nable to arthroscopic repair. We out-line our stepwise technique for ar-throscopic repair of full-thicknessrotator cuff tears (using triple-loadedsuture anchors) and report the keysteps necessary for maximizing effi-ciency and reproducibility.

Indications

Standard protocol encourages a peri-od of nonsurgical management forrotator cuff tears. Older patientswith mild symptoms and chronictears are excellent candidates for

nonsurgical management, such asanti-inflammatory modalities aswell as strengthening of the deltoidmuscle, periscapular stabilizer mus-cles, and inferior intact rotator cuffmuscles. However, young patientswith traumatic rotator cuff injuriesshould be considered for immediaterepair because full-thickness rotatorcuff tears do not heal or reattach ontheir own and are likely to progressto rotator cuff arthropathy. In themiddle-aged patient, the decision ofwhether and when to recommendsurgery can be more difficult.

Although nonsurgical treatmentof full-thickness tears is successfulin the short-term for many patients,long-term success is not guaranteed.Without surgical reapproximation,the torn rotator cuff does not heal tobone. Additionally, the muscles un-dergo progressive atrophy and fattyinfiltration over time. When neglect-ed for too long, reparable rotator cufftears with good tissue and favorableprognoses can become irreparable,with poor tissue and poor prognoses.For these patients, an extended peri-od of nonsurgical management maylead to long-term complications. Ac-tive, healthy patients with symp-tomatic full-thickness rotator cufftear should be thoroughly counseledand seriously considered for surgicalrepair earlier rather than later. Aswith any surgical procedure, it iscrucial to determine the needs andgoals of each patient; educate the pa-tient about options, risks, and bene-fits; and tailor the treatment recom-mendations accordingly.

Dr. Burns is Associate, ShoulderArthroscopy Team, Southern CaliforniaOrthopedic Institute, Van Nuys, CA.Dr. Snyder is Director, ShoulderArthroscopy Team, Southern CaliforniaOrthopedic Institute. Dr. Albritton isSports Medicine Specialist, ResurgensOrthopaedics, Peachtree City, GA.

Dr. Burns and Dr. Albritton or the depart-ments with which they are affiliated havereceived nonincome support (such asequipment or services), commerciallyderived honoraria, or other non-re-search–related funding (such as paidtravel) from Mitek. Dr. Snyder or the de-partment with which he is affiliated hasreceived royalties from and serves as aconsultant to or is an employee ofConMed Linvatec and Arthrex.

Reprint requests: Dr. Burns, SouthernCalifornia Orthopedic Institute, 6815Noble Avenue, Van Nuys, CA 91405.

J Am Acad Orthop Surg 2007;15:432-444

Copyright 2007 by the AmericanAcademy of Orthopaedic Surgeons.

Joseph P. Burns, MD

Stephen J. Snyder, MD

Mark Albritton, MD

The video that accompaniesthis article is “ArthroscopicRotator Cuff Repair,” availa-

ble on the Orthopaedic KnowledgeOnline Website, at http://www5.aaos.org/oko/jaaos/surgical.cfm

Surgical Techniques

432 Journal of the American Academy of Orthopaedic Surgeons

http://www5.aaos.org/oko/jaaos/surgical.cfm

Contraindications

Contraindications to rotator cuff re-pair include severe osteoarthritis ofthe glenohumeral joint, overridingmedical comorbidities, and activitydemands sufficiently low to toleraterotator cuff deficiency. For patientswith concomitant adhesive capsuli-tis, we prefer to rehabilitate the stiffshoulder before performing rotatorcuff repair. Patients with failed priorrotator cuff surgery and significantfatty infiltration should be coun-seled that the outcome generally isless predictable.

Surgical Technique

Preoperative ImagingPreoperatively, four standard ra-

diographic views are obtained of theinjured shoulder: “true” anteropos-terior (perpendicular to the plane ofthe scapula), lateral supraspinatusoutlet, axillary, and Zanca (acromio-clavicular [AC] joint).1 Done correct-ly, these views give a thorough ap-preciation of bony anatomy. Thesupraspinatus outlet view also isused to classify and determine thethickness of the acromion.

The acromion is classified preop-eratively by shape according to theclassification of Bigliani and Morri-son:2 type 1, flat acromion; type 2,gently curved acromion; and type 3,acromion with a sharp inferior“beak.” The surgeon considering sub-acromial decompression or a smooth-ing procedure should be aware of theamount of bone available. Acromialthickness can vary widely. Thus, wealso classify the acromion based onthickness: type A, <8 mm; type B, 8to 12 mm; and type C, >12 mm.These measurements are made on thesupraspinatus outlet view, as well,1.5 to 2 cm behind the anterior edgeof the acromion in an area that cor-responds to the posterior aspect of theAC joint. Most of our patients havepresented with type 2B acromialarches. We write this classification di-rectly on the radiograph as a visual re-

minder in the operating room.For most patients, we order pre-

operative magnetic resonance imag-ing scans, without contrast. A high-quality magnetic resonance imagingscan provides a great amount of in-formation regarding the status of therotator cuff tendon, surroundingmuscle bellies, subscapularis and bi-ceps tendons, AC and glenohumeraljoints, soft-tissue quality, and bonequality. Sagittal oblique (perpendic-ular to the scapula), coronal oblique(parallel to the scapula), and axialcuts are all useful. The coronal viewoften best demonstrates supraspina-tus tears; the sagittal view also mayshow signs of lateral tendon injuryof the supraspinatus footprint aswell as the quality and mass of themuscle belly as it lies in the su-praspinatus fossa more medially(Figure 1). Significant fatty infiltra-tion in the medial muscle mass maybe a poor prognostic indicatorof functional outcome, and patientsshould be counseled appropriatelyduring the preoperative discussion.

Patient PositioningShoulder arthroscopy is per-

formed with the patient in the later-al position under general anesthesia.Lateral positioning provides easy ac-cess to all areas of the shoulder andallows safe, low blood pressure con-trol during anesthesia, thus mini-mizing bleeding and maximizing vi-sualization. After placement of theendotracheal tube, the patient iscarefully turned onto his or her side,and an axillary roll is placed. In mak-ing the turn, the anesthesiologistcontrols the head, the surgeon andassistant move the torso, and the cir-culating nurse controls the legs. Thelegs are flexed to a comfortable, bal-anced position and are padded, withpillows placed between the kneesand foam pads under the dependentankle and peroneal nerve area. Abeanbag is used to support the torso,with the thorax tilted approximate-ly 20° posteriorly (Figure 2). Warmblankets are placed over the patient,

and safety straps are applied acrossthe torso. The table is then rotated45° posteriorly to allow the surgeoneasy access to both sides of theshoulder.

The shoulder is prepped anddraped. The upper limb is placed ina sterile traction sleeve in 70° of ab-duction and 20° of forward flexionunder 8 to 10 lb of traction using ashoulder traction device affixed tothe foot of the bed. A watertight sealbetween the skin and the drapes isessential. Runoff bags attached tothe drapes should be positioned tocollect both anterior and posteriorfluid. Appropriate bony landmarksare drawn on the shoulder, includingthe acromion, clavicle, AC joint, andcoracoid. An orientation line isdrawn, extending laterally from theposterior edge of the AC joint, per-pendicularly across the acromion,and down the deltoid 4 cm (Figure 3).This line should divide the acromioninto an anterior two fifths and a pos-terior three fifths. Anterior to thisline are the subacromial bursa, bi-ceps tendon, and supraspinatus in-

Figure 1

Sagittal magnetic resonance image ofan atrophied supraspinatus musclebelly (S) in the supraspinatus fossa.The medial scapula can be seen oneither side of the supraspinatus. F =fatty infiltration, IS = infraspinatusmuscle, SSC = subscapularis muscle,TM = teres minor muscle

Joseph P. Burns, MD, et al

Volume 15, Number 7, July 2007 433

sertion. Just posterior to this line arethe posterior limit of the bursalspace and the posterior bursal cur-tain. As surgery progresses, this ori-entation line is a helpful referencefor accurately creating the lateralsubacromial portal and accessing thesubacromial structures. The posteri-or portal position is also marked onthe skin, approximately 2 cm inferi-or and 1 cm medial to the posterolat-eral acromial corner.

The surgeon can use either a

gravity- or a pump-driven fluid con-trol system. We prefer to use a pumpwith which both the flow and thepressure can be controlled.

Arthroscopic EvaluationArthroscopic rotator cuff repair

should begin with a standardized, re-producible arthroscopic examina-tion of the complete intra-articularanatomy via both the posterior andthe anterior portals. A standardizedevaluation minimizes the chance of

missing important pathology (eg,loose bodies, subscapularis tears, su-perior labrum anteroposterior tears,chondral damage) in the haste to ad-dress the rotator cuff.

A small skin incision is made,and the arthroscope is placed in thejoint posteriorly. The joint is dis-tended with saline via the arthro-scopic pump. An inside-out tech-nique is used to create the standardanterior midglenoid portal: the bi-ceps and subscapularis tendons arevisualized, and the arthroscope is ad-vanced up against the rotator inter-val tissue between these two ten-dons. The arthroscope is thenremoved from its sheath, and atapered-tip guide rod is passedthrough the sheath and is used tobluntly penetrate the anterior cap-sule, rotator interval, and anteriordeltoid until the tip can be felt sub-cutaneously. The tip is angled slight-ly superior and lateral to avoid thecoracoacromial ligament, and asmall incision is made over the pal-pable guide rod tip anteriorly. Thisincision is usually approximately2 cm inferior and 1 cm medial to theanterolateral acromial edge. Theguide rod tip is passed through theanterior incision, and an anteriorcannula is inserted over the rod andgently worked back into the jointuntil it abuts the end of the scopesheath. Holding the position of eachcannula stable, the guide rod is re-moved and the arthroscope is rein-serted posteriorly. Outflow is thenattached to the anterior cannula, anda complete diagnostic examinationis performed.

A standard 15-point arthroscopicexamination is performed in all pa-tients3 (Table 1). It is imperative thatthe surgeon evaluate each shoulderwith a reproducible, consistent ex-amination.

Surgical Preparation andFixation

The frayed edges of the rotatorcuff tendon on the articular side aredébrided through the posterior and

Figure 2

Lateral patient positioning with beanbag stabilization.

Figure 3

With the patient in the lateral position, all relevant bony landmarks are marked,including an orientation line.

Arthroscopic Rotator Cuff Repair Using Triple-Loaded Anchors, Suture Shuttles, and Suture Savers


anterior portals, taking care to re-move as much as possible of the re-maining fragments of tendon fromthe “footprint” area. Placing theshaver above the biceps tendon usu-ally allows better access to the tu-berosity ( video, 0:40). Switchingthe arthroscope anteriorly and theshaver posteriorly is an especially ef-fective technique for footprint dé-bridement. Undersurface débride-ment from within the joint isparticularly important because itcan be difficult to visualize thisanatomy when the arthroscope islater changed to the bursal position.

After undersurface débridement,the arthroscope is inserted into thebursa through the posterior portal,and the anterior outflow cannula isplaced through the anterior portal.Before insertion of the arthroscope,however, the arm traction device isadjusted to change the arm positionto 30° of abduction and 5° of flexion.This improves bursal visualizationand moves the arm to the side, en-suring that the repair will not be un-

der excess tension. Adding up to 5 lbmore of traction may improve theworking space, as well. A completebursal evaluation is performed fromthe anterior and posterior portals.

Viewed from the anterior portal,the posterior bursal “curtain” tissueoverlying the posterior rotator cufftendon fibers is débrided ( video,2:27), as is any thickened bursal tis-sue laterally to improve visualizationof the cuff. This preparation becomesuseful later, once the arthroscope isreturned to the posterior portal. Al-though this bursal tissue may notseem to be a problem early on, it canbecome swollen and occlude visual-ization later in the operation.

The arthroscope is returned pos-teriorly, a lateral acromial portal(LAP) is created, and the cannula isplaced. Because the LAP is the mainviewing portal during the repair, theportal must be located in a positionthat is directly in line with the cen-ter of the rotator cuff tear (Figure 4)and at least 2.5 cm lateral from theacromial edge. A spinal needle is

used to assess proper portal place-ment before making the incision.

Selective subacromial smoothingand a mini or complete distal clavi-cle resection is performed as needed,based on preoperative radiographicfindings, patient symptoms, andthe arthroscopic findings ( video,4:15).

Where the tendon has been torn,the bone on the humerus adjacent tothe cartilage edge is shaved andlightly burred; this is continued lat-erally for 1.5 cm over the greater tu-berosity. Taking care not to injure theundersurface deltoid muscle fibers,the residual soft tissue on the greatertuberosity and just enough of the cor-tex are removed to stimulate bleed-ing without excessively weakeningthe bone. With good healing, thisarea will supply much of the neces-sary blood supply. It will be coveredwith new tissue as the healing cuffedge spreads out to regenerate a foot-print of attachment (Figure 5).

With the arthroscope in the LAP,preparation of the torn edge of therotator cuff is completed. The thin,feathered edge of tendon is removedusing a square-nosed biter and/orshaver ( video, 7:17).

The tear pattern is assessed withan arthroscopic grasper placedthrough the anterior and posteriorcannulae. The pattern of the tear is

Table 1

Fifteen-Point Glenohumeral Anatomy Examination

Visualizing From the Posterior Portal1. Biceps tendon and superior labrum2. Posterior labrum and capsular recess3. Inferior axillary recess and inferior capsular insertion on the humerus4. Inferior labrum and glenoid articular surface5. Supraspinatus tendon insertion6. Posterior rotator cuff insertion and bare area on the humeral head7. Articular surface of the humeral head8. Anterior-superior labrum, superior and middle glenohumeral

ligaments, and subscapularis tendon9. Anteroinferior labrum

10. Anteroinferior glenohumeral ligament

Visualizing From the Anterior Portal11. Posterior glenoid labrum and capsule insertion into the humeral head12. Posterior rotator cuff, including the infraspinatus and teres minor13. Anterior glenoid labrum, inferior glenoid labrum, and inferior

glenohumeral ligament attachments to the humeral head14. Subscapularis tendon and recess and middle glenohumeral ligament

attachment to the labrum15. Anterior surface of the humeral head with subscapularis attachment and

biceps passage through the rotator interval

Figure 4

From a posterior view, the lateral portalis established at the midpoint of thetear.







established, tension is evaluated,and the position of tendon repair isplanned.

Side-to-Side Rotator CuffSutures

Placement of side-to-side suturesto close the vertical component of anL- or V-shaped tear is an importantadvancement in the ability to repairlarger lesions. Side-to-side suturesare important for two reasons: theymay help to reestablish the properalignment of the torn tendon endswith their insertion site on the hu-merus (especially important withL-shaped tears), and they can relievestress on the lateral tendon-to-bonerepair.

The single-pass side-to-side stitchis used when the two sides of a tearare relatively well-aligned. Thisstitch is made using a crescent-shaped suture hook with an absorb-able monofilament suture or a per-manent braided suture.

The crescent hook is insertedthrough either the anterior or poste-rior cannula, whichever is mostdirect. The hook is aligned by layingit over the top of the tear in the di-rection of the desired stitch. For a V-or L-shaped tear, the first stitchshould be placed medially, near theapex.

The needle is backed out to a

point 1 cm from the tear edge. Thecurve of the needle is turned towardthe tendon, and the needle is driventhrough it with gentle pressure, tak-ing care not to injure the underlyingarticular cartilage on the humerus.

The needle is passed through thenear side of the tear, then turned up180° so that the curve is facing to-ward the acromion. The surgeonshould take care to observe the tip inthe cleft between the two sides ofthe tear. The tip is advanced underthe far side of the tear and directedthrough to exit 1 cm away from theedge (Figure 6, A). An assistant stabi-lizes the cuff edge with a grasperclamp during passage of the stitcher.Excessive force may break thestitcher tip, so firm but gentle ma-neuvers should be used.

A Shuttle Relay Suture (ConMedLinvatec) is passed through the nee-dle and retrieved out of the oppositecannula with a grasper clamp. Theshuttle eyelet is loaded with a suture(Figure 6, B) and carried back downthe cannula, across the tear, and outthe initial cannula (Figure 6, C). Bothsuture limbs are collected from eitherthe anterior or posterior cannula,based on whichever offers the bestaccess to the tear. The suture limbsare tied using a sliding locking knot(Figure 6, D).

Side-to-side stitching is repeated

as needed to close the intertendinousdefect (Figure 7). In many instances,intertendinous defects cannot beclosed in one step. For these tears,we often use a two-step side-to-sidestitch, in which the suture is passedand shuttled through each side ofthe tear individually. Whether suchstitches truly heal tendon tissueback together is a matter of debate,but side-to-side sutures are effectivein reducing both tear volume andtension on lateral anchor-basedstitches.

Suture Anchor Fixation ofRotator Cuff Tears to Bone:Triple-Loaded Anchors

Triple-loaded suture anchorsmaximize the strength of thetendon-bone construct over eitherdouble- or single-loaded anchors,thus minimizing the risk of tendon-suture failure.4 Triple-loaded sutureanchors may allow the surgeon touse fewer total anchors on sometears. Suture management is slight-ly more complicated with this meth-od, but with practice and careful at-tention to detail, it can becomeroutine. With three sutures, variousstitching patterns can be employed,including three simple stitches ortwo simple stitches with the thirdused as a central mattress-typestitch.

Figure 5

T2-weighted serial coronal oblique magnetic resonance images demonstrating lateral expansion of the healing tissue at4 weeks (A), 2 months (B), and 2 years (C) after arthroscopic repair to the medial supraspinatus footprint.



Still viewing from the LAP, a spi-nal needle is inserted percutaneous-ly and adjacent to the lateral acromi-on to determine the proper positionand angle for suture anchor place-ment. When the position and angleof the spinal needle are appropriatefor anchor placement, a no. 11 bladeis used to create a small stab incision(3 to 5 mm) in the skin. Careful po-sitioning and planning may allowtwo or three suture anchors to beplaced into the tuberosity throughthe same stab incision. For largertears, however, two different entrysites may be required. The posterioranchor is inserted first. The angle ofentrance into the bone is crucial; itmust approach the humeral head at

an angle heading like that of a “tentpeg” under the subchondral bone( video, 11:52). With too verticalan insertion angle, the anchor willenter the softer bone of the tuberos-ity rather than the dense subchon-dral bone of the humeral head, there-by increasing the risk of anchorpull-out failure.

Before placing the anchors, weprefer to place pilot holes—each ap-proximately 1 cm apart in the pre-pared bone bed—3 to 5 mm lateral tothe articular cartilage edge. This areacorresponds to the medial extent ofthe normal rotator cuff insertion; an-chor placement here minimizes therisk of overtensioning the repair byexcessively lateralizing the repair

Figure 7

Two side-to-side stitches effectivelyclose a large defect.

Figure 6

Side-to-side stitch technique. A, The tear is visualized from the lateral portal, and the crescent-shaped stitcher is passed throughthe cuff. A Shuttle Relay Suture (ConMed Linvatec, Largo, FL) is passed out the opposite portal. A suture eyelet is loaded (B),and the suture is passed back through the tendon (C). D, A sliding locking knot is tied. A = acromion, B = long head of bicepstendon, C = clavicle, Co = coracoid, T = location of the torn tendon




site. A pilot hole punch (often in-cluded with the suture anchor set) isinserted through the small stab skinincision. The punch vectors are di-rected so that the posterior hole an-gles slightly posteriorly and the an-terior hole angles slightly anteriorly.Fanning out the holes in this wayensures that each anchor has a solidwall of surrounding bone.

The ThRevo (ConMed Linvatec)triple-loaded suture anchor comesloaded with three differently coloredbraided sutures. Other brands of an-chor also may allow the surgeon tomanually load a third suture into theeyelet. The ThRevo anchor has avertical guide mark on the insertionhandle shaft perpendicular to theeyelet hole, which marks the suturealignment within the eyelet.

The first anchor is insertedthrough the skin incision used forthe pilot hole punch ( video,12:10). The posterior anchor isplaced first. It is screwed into thebursal space through the deltoidmuscle, and the anchor tip is seatedinto its pilot hole. The screw isaligned so that it follows the direc-tion of the pilot hole, seating intothe bone at an angle of approximate-ly 45°. The vertical guide mark mustbe directed toward the cuff (ie, to-ward the desired direction in whichthe sutures will pass). The anchoreyelet will be parallel to the articu-lar surface/cuff edge, and the suturespassing through it thus will be per-pendicular to the articular surface/cuff edge.

Suturing TechniqueA recent study by Coons et al4

compared the strength under repeti-tive loading of various stitching pat-terns with two and three sutures peranchor. An anchor with three simplesutures passed through the cuff wasthe strongest construct, while twosimple sutures with a central mat-tress passing through the same holesas the simple sutures was secondstrongest. This was followed by twosimple sutures with a separate cen-

tral mattress. The least strong wastwo simple sutures alone.

Three Simple-StitchTechnique

After placing the anchor in thebone (Figure 8, A), the surgeonshould pull with gentle tension onthe suture ends; their orientationwithin the eyelet can be appreciatedjust below the surface of the bone( video, 12:39). The posterior,middle, and anterior sutures must bedefined, as must which suture limbsexit the eyelet on the cuff/medialside and which exit on thetuberosity/lateral side. Gentle see-sawing of the suture ends aids in set-ting the sutures in organized posi-tions within the eyelet.

Using a loop grasper or crochethook, the most posterior cuff-sidesuture is retrieved from the anteriorcannula, taking care to stay medialto the remaining suture strands (Fig-ure 8, B). This suture strand will bepassed up through the cuff as thefirst simple stitch in a posterior-to-anterior progression.

For stitching through the tendon,the surgeon should use a suturehook that affords the best angle forpassage through the cuff via the pos-terior portal. The first, most posteri-or pass often is best achieved with acrescent-shaped stitcher. The stitch-er is passed through the cuff fromtop to bottom, approximately 8 mmposterior to the anchor and 1 cm me-dial to the free edge. The surgeonshould visualize the needle tip exit-ing the bottom of the cuff end andfeed the suture shuttle through it 1to 2 in (Figure 8, C).

Passing medial to the remainingsutures in the anchor, the shuttleend is retrieved with a grasper andcarried out of the anterior cannula,where the anchor suture strand al-ready lies. For ease of suture man-agement, the suture strand, sutureshuttle, and grasper must follow thesame path behind the other sutures.This will prevent entangling a pass-ing suture with a so-called bystand-

er suture that has yet to be used.The shuttle is loaded with the su-

ture outside the anterior cannula(Figure 6, B) and is carried backthrough the cuff from bottom to top,then out the posterior portal (Figure8, D). The suture is removed fromthe shuttle eyelet, and its partnerlimb (tuberosity-side suture) is re-ceived out of the posterior cannula(Figure 8, E). Both posterior limbswill then be together within the pos-terior cannula in a simple stitch for-mation through the cuff. They arenot tied until all other sutures havebeen passed. Tying the suture at thispoint restricts cuff mobility andmakes it more difficult to pass sub-sequent stitches.

To begin the suture saving pro-cess ( video, 13:38), a switchingstick is placed in the posterior can-nula to hold its position, and thecannula is backed out of the skinover the switching stick. The su-tures are removed from inside thecannula, and the pair is loaded into aSuture Saver (ConMed Linvatec).The Suture Saver is a thin straw-liketube that holds both ends of the su-ture together, protected and orga-nized within its cannula. A clamp isplaced at the end of the Suture Sav-er outside the shoulder to hold it inplace. Then the cannula is replacedback over the switching stick intothe subacromial space, with the su-ture strands stored together outsidethe cannula but inside the SutureSaver. At the end of this process, oneset of sutures is passed and is safelyprotected from entanglement withinthe Suture Saver (Figure 8, F).

Next, the middle suture strand isretrieved from the anchor. Thestrand that exits the anchor closestto the cuff edge is brought out of theanterior cannula as before ( video,14:38). A suture hook is insertedagain and passed through the cufffrom top to bottom in line with themiddle of the anchor and approxi-mately 1 cm medial to the cuff edge(Figure 8, G). The shuttle is ad-vanced through the suture hook tip







and carried out the anterior cannula.The suture is loaded and carriedback through the cuff, as was donewith the posterior suture (Figure 8,H). The middle suture partner(tuberosity-side) strand is retrieved;both strands are placed together in aSuture Saver outside the posteriorcannula (Figure 8, I). The third, mostanterior suture strand on the cuffside of the eyelet is retrieved, andthe stitcher and shuttle are passedand then shuttled back through thetendon, approximately 8 mm anteri-or to the anchor. These suturesshould be placed in a Suture Saver ifadditional anchors/stitches are to beplaced (Figure 8, J).

The subsequent anchor or anchorsare inserted anterior to the first, andthe best portal (anterior or posterior)is determined for passage of each su-ture. The cuff is stitched as describedabove, and each set of paired strandsis placed into savers. As the repairprogresses, each pair of sutures is heldfirmly and safely in Suture Savers,creating an organized collection ofsavers (Figure 9, A) and avoiding su-ture entanglement (Figure 9, B).

Two Simple Sutures With aCentral Mattress Technique

Using steps nearly identical to thethree simple-stitch technique, thesurgeon can make two simple su-tures as well as a central mattresswith only two passes of the stitcher.Both cuff-side strands are retrievedfrom the posterior and middle su-tures in the eyelet and are broughtout of the anterior cannula. Forstitching, the surgeon should choosethe suture hook that affords the bestangle for passage through the cuff viathe posterior portal. The hook ispassed through the cuff from top tobottom, approximately 8 mm poste-rior to the anchor and 1 cm medialto the free edge of the tendon. Thesurgeon should visualize the needletip exiting the bottom of the cuff endand feed 1 to 2 in of suture shuttlethrough.

Approaching medial to the rest of

the sutures in the anchor, the shut-tle is retrieved with a grasper andcarried out the anterior cannula. Forease of suture management and toavoid tangling with a bystanderstrand, the suture strand, sutureshuttle, and grasper must follow thesame path medial to the other su-tures. The shuttle is loaded withboth sutures outside the anteriorcannula, and both sutures are carriedback through the cuff and out theposterior cannula. The partner limbof the posterior suture is retrievedonly out of the posterior cannula;the tuberosity-side partner limb ofthe middle suture is left in place.The posterior sutures are saved in aSuture Saver. The switching stick isplaced in the posterior cannula, andthe cannula is backed out of theskin. All three of the sutures arethen removed from inside the can-nula, and the posterior pair is loadedinto a Suture Saver. With the poste-rior sutures in it, the Suture Saver isclamped, and the cuff-side middlesuture alone is left outside the can-nula. The cannula is replaced overthe switching stick with the threesuture limbs outside the cannula.

Both the remaining limb (tuber-osity-side) of the middle suture aswell as the cuff-side limb of the an-terior suture are retrieved out the an-terior cannula. A suture hook is in-serted a second time and passedthrough the cuff from top to bottom,this time anterior to the anchor andapproximately 1 cm medial from thecuff edge. The shuttle is sentthrough the needle and out the oppo-site cannula, after which both su-tures are loaded into the shuttle andcarried back through the cuff and outthe posterior stitching portal. The fi-nal suture left in the anchor (thetuberosity-side limb of the anteriorsuture) is retrieved, and the anteriorsuture pair and the middle suturepair are placed in separate SutureSavers, outside the posterior cannu-la, along with the posterior suturepair that was saved in the first step.After two passes with the stitcher,

the posterior and anterior suturepairs are tied to form a simple stitchpattern. The middle suture pairs aretied, forming a mattress pattern.

Securing the Rotator CuffAfter placing all sutures through

the cuff from posterior to anteriorand subsequent storage of each pairwithin Suture Savers, each suture isthen tied sequentially back from an-terior to posterior ( video, 18:54).We prefer to use SMC (SamsungMedical Center) sliding lockingknots5 backed up with threealternating-post half-hitches. To tiesutures in direct line with their pas-sage through the anchor eyelet, tyingis performed through the lateral por-tal while visualizing with the arthro-scope in the anterior portal. Each su-ture pair is easily identified in itsrespective Suture Saver, removedout the tying cannula, and tied with-out risk of complicated tangling.

After all sutures are tied, the cuffedge is visualized and palpated to en-sure that it is stable (Figure 10, A).The surgeon may also replace the ar-throscope into the glenohumeraljoint to evaluate the undersurface ofthe repair (Figure 10, B). The portalsare closed using a single absorbablesubcutaneous suture and Steri-Strips(3M, St. Paul, MN).

Postoperative dressing is applied.ProWick ColdWrap dressing (RedynsMedical, Los Angeles, CA) providesultra-absorbent, compressive cover-age, drawing fluid away from the in-cision sites and into the dressing.Cold therapy is effective with thelow-profile ProWick; this dressing issecured with a gentle compressivewrap rather than with skin tape, al-lowing easy removal without pain orskin irritation (Figure 11). After thedressing is applied, the arm is sup-ported in a sling with a neutral ab-duction pillow.

Postoperative Care

Postoperative management consistsof protecting the cuff repair in a neu-




Figure 8

Three simple-stitch technique. A, The most posterior anchor is placed percutaneously, 2 to 3 mm lateral to the edge of thehumeral articular surface. B, Using a stepwise approach, the most posterior cuff-side suture is identified and taken from theanchor eyelet out the anterior cannula with a crochet hook. C, A tendon stitcher is used to penetrate the tendon and pass asuture shuttle (black) through the tissue, where it is grasped and brought out of the anterior cannula with the aforementionedsuture. The suture shuttle is advanced through the stitcher, across the tendon, and out the anterior cannula until its open eyelet(used to hold the suture) is advanced out the anterior cannula. D, The end of the suture is placed through the shuttle eyelet,and both the shuttle and the suture held within its eyelet are pulled, via the posterior cannula, back through the subacromialspace, across the tendon, and out posteriorly. The partner tuberosity-side suture is retrieved our the posterior cannula (E), andthe paired ends are placed together in a Suture Saver (ConMed Linvatec) and stored outside the cannula (F).



tral rotation sling for approximately4 weeks. The amount of time re-quired in the sling depends on the se-verity of the tear, the quality of thecuff and bone tissue, and the securi-ty of the repair. On the day of sur-gery, the patient begins exercises, in-cluding squeezing a small rubberball and performing active elbow,

wrist, and hand movements. Shoul-der shrugs and scapular adductionexercises are begun on the first post-operative day. The incisions are keptdry for 10 days; showers are allowedas long as the wounds are coveredwith waterproof plastic wrap. An-teroposterior and outlet radiographsare obtained during the first postop-

erative visit to document the posi-tion of the anchors and evaluate thesubacromial decompression.

Pendulum exercises are begun af-ter the first week. As long as the sub-scapularis and posterior cuff are in-tact, gentle isometric internal andexternal exercises with the arm inneutral rotation are added. Formal

Figure 8 (continued)

G-J, This process is repeated for each subsequent suture inthe triple-loaded anchor. K, A completed repair with two side-to-side sutures and three triple-loaded anchors.



physical therapy for passive range ofmotion begins at 4 weeks, and aqua-therapy is offered as well. Active-assisted elevation with a pulley isbegun at 6 weeks. Resisted exercisesfor the cuff and scapula are addedprogressively after 8 weeks as symp-toms allow. At 3 months, most usu-al daily activities are allowed, butthe patient should not engage in anystrenuous work or sports requiringheavy lifting, nor make quick move-ments. Although the tendon shouldbe fairly well healed to bone withSharpey’s fibers by 3 months, it maytake at least 1 year for the muscles toregain substantial strength.

Results

In 2002, Murray et al6 reported theresults of 45 patients with 48 medi-um to large cuff repairs that weremanaged arthroscopically. Averagepatient age was 57.6 years, and meanfollow-up was 39 months (range,24–66 months). Shoulder pain, asrated on the UCLA shoulder index(scale of 10), improved from 3.3 pre-operatively to 9.3 at follow-up. Func-tion improved from 5.4 to 9.5. Per-haps the most important parameteris patient satisfaction with surgery.On a scale of 0 to 5, this score im-proved from 0 preoperatively to 4.9

postoperatively. No patient regrettedhaving had the operation.

A Southern California Orthope-dic Institute study currently submit-ted for publication found that 37 pa-tients younger than age 50 years whounderwent arthroscopic rotator cuffrepair achieved a mean postopera-tive UCLA score of 32.3 out of 35 ata mean 5.8-year follow-up. These pa-tients had significant improvementsin pain and strength postoperatively,and no patient had required revisionrepair at time of follow-up.7 Theseresults are superior to thoseachieved in other studies in whichyounger patients were treated withan open technique.8-10

Most other published studies sug-gest that the short- and mid-term re-sults of all-arthroscopic repairs arestatistically similar to those of openand mini-open techniques.11-14 Oth-ers suggest that diminished pain,motion, and even strength may bebetter in arthroscopically treatedtears.15-17 Long-term outcome stud-ies are needed. Because some ques-tion remains as to which repair tech-nique is superior, we recommendthat each surgeon use the techniquewith which he or she feels mostcomfortable.

Figure 9

Suture Savers (ConMed Linvatec) provide organization and protection for pairedsuture ends within the shoulder before knot-tying, allowing the tendon to remainaccessible and mobile as stitching progresses. B, Without this organization, thesutures often become entangled.

Figure 10

A, Arthroscopic image demonstrating three tied sutures, which are well spread out.The tendon is firmly reattached to the bone. B, Intra-articular view confirminganatomic repair.

Figure 11

Postoperative application of theProWick ColdWrap dressing (Arthrex,Naples, FL). This dressing has no skintape and can be easily removed fromthe patient without irritation.



Summary

Arthroscopic repair of rotator cufftears is an effective and straightfor-ward technique when performed inan organized, well-considered man-ner. We carefully developed our tech-nique over many years, but it is notthe only one capable of achieving ex-cellent results. We encourage anyoneinterested in making the transition toarthroscopy to practice his or hertechnique outside the operatingroom on shoulder models or cadav-eric specimens. With practice and ex-perience, the numerous, seeminglycomplex steps can be learned and log-ically understood. The surgeon canidentify and correct suture manage-ment pitfalls, learn dexterity withthe instruments, perfect knot-tying,and develop a general comfort levelwith the anatomy. These skills,learned and perfected outside the op-erating room, will significantly re-duce the number of disruptions thatcan occur inside the operating room.

References

Citation numbers printed in boldtype indicate references publishedwithin the past 5 years.

1. Zanca P: Shoulder pain: Involvementof the acromioclavicular joint. (Anal-ysis of 1000 cases). Am J RoentgenolRadium Ther Nucl Med 1971;112:493-506.

2. Bigliani LU, Morrison DS, April EW:The morphology of the acromion andits relationship to rotator cuff tears.Orthop Trans 1986;10:216.

3. Snyder SJ: Diagnostic arthroscopy ofthe shoulder, in Snyder SJ: ShoulderArthroscopy, ed 2. Philadelphia, PA:Lippincott, Williams & Wilkins,2003, pp 22-38.

4. Coons DA, Barber FA, Herbert MA:Triple-loaded single-anchor stitch con-figurations: An analysis of cyclicallyloaded suture-tendon interface secu-rity. Arthroscopy 2006;22:1154-1158.

5. Kim SH, Yoo JC: Arthroscopic knot-tying. Techniques in Shoulder &Elbow Surgery 2003;4:35-43.

6. Murray TF Jr, Lajtai G, Mileski RM,Snyder SJ: Arthroscopic repair of me-dium to large full-thickness rotator

cuff tears: Outcome at 2- to 6-yearfollow-up. J Shoulder Elbow Surg2002;11:19-24.

7. Burns JP, Snyder SJ: Arthroscopic ro-tator cuff repair in patients youngerthan 50 years of age. J ShoulderElbow Surg, in press.

8. Watson EM, Sonnabend DH: Outcomeof rotator cuff repair. J ShoulderElbow Surg 2002;11:201-211.

9. Tibone JE, Elrod B, Jobe FW, et al: Sur-gical treatment of tears of the rotatorcuff in athletes. J Bone Joint Surg Am1986;68:887-891.

10. Sperling JW, Cofield RH, Schleck C:Rotator cuff repair in patients fiftyyears of age and younger. J Bone JointSurg Am 2004;86:2212-2215.

11. Verma NN, Dunn W, Adler RS, et al:All-arthroscopic versus mini-open ro-tator cuff repair: A retrospective re-view with minimum 2-year follow-up. Arthroscopy 2006;22:587-594.

12. Sauerbrey AM, Getz CL, PiancastelliM, Iannotti JP, Ramsey ML, WilliamsGR Jr: Arthroscopic versus mini-openrotator cuff repair: A comparison ofclinical outcome. Arthroscopy 2005;21:1415-1420.

13. Kim SH, Ha KI, Park JH, Kang JS, OhSK, Oh I: Arthroscopic versus mini-

Pearls• The technique should be practiced outside the operating room on models, at laboratories, or at courses.

The surgeon who is comfortable with a mini-open approach can progress with the arthroscopic approachas far as possible and then convert to mini-open (possibly after a predetermined period of time) to critiquehis or her progress and technique.

• Translucent cannulas should be used to maximize visualization. To accept most curved stitchers, flex-ible cannulas must be >6.5 mm in diameter, while stiff cannulas must be >8.0 mm. Two smooth metalswitching sticks are invaluable when moving cannulas around the shoulder.

• Runoff bags should be carefully positioned to keep the patient dry.• Fluid pressure should be monitored and adjusted as needed to maximize visualization and minimize

shoulder swelling.• Complete bursectomy, especially posteriorly and laterally, should be done early in the procedure because

the bursa can swell over time and become a problem.• When grasping and shuttling sutures in and out of the shoulder, the surgeon must take care to watch the

suture in the anchor eyelet so as not to unload it (ie, pull it entirely out of the eyelet).• Suture ends should be stored in Suture Savers to prevent entanglement and to allow the cuff to stay some-

what mobile while passing subsequent stitches.• The surgeon should educate his or her assistants and cultivate their understanding of the process.

Pitfalls• Sloppy patient positioning will lead to inferior and unpredictable access to the shoulder.• The surgeon should understand the fluid management system in order to be able to troubleshoot when

problems arise.• The surgeon must not cut corners. Diligence in following the proper steps will pay off by avoiding more

time-consuming mistakes, such as suture entanglement and unloading of the anchor.



open salvage repair of the rotator cufftear: Outcome analysis at 2 to 6 years’follow-up. Arthroscopy 2003;19:746-754.

14. Youm T, Murray DH, Kubiak EN, Ro-kito AS, Zuckerman JD: Arthroscopicversus mini-open rotator cuff repair:A comparison of clinical outcomes

and patient satisfaction. J ShoulderElbow Surg 2005;14:455-459.

15. Severud EL, Ruotolo C, Abbott DD,Nottage WM: All-arthroscopic versusmini-open rotator cuff repair: A long-term retrospective outcome compari-son. Arthroscopy 2003;19:234-238.

16. Buess E, Steuber KU, Waibl B: Open

versus arthroscopic rotator cuff re-pair: A comparative view of 96 cases.Arthroscopy 2005;21:597-604.

17. Warner JJ, Tetreault P, Lehtinen J,Zurakowski D: Arthroscopic versusmini-open rotator cuff repair: A co-hort comparison study. Arthroscopy2005;21:328-332.



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Arthroscopic Rotator Cuff Repair

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