Arthroscopic Trans-Osseous Tension Band Rotator Cuff Repair

Arthroscopic rotator cuff repair tends to create the impression with patients, physicians, and the general public that it is a uniform technique that is consistently taught and performed the same way all over the world. This simply isn’t true, and one known factor that contributes to failed rotator cuff repairs is surgical skill and experience. Surgical technique has also been shown to be a factor in the risk for both healing and the development of subsequent rotator cuff tear. Although, we have written extensively over the years about rotator cuff tears as well as posted a number of videos about this topic, many patients have asked for a step by step description of the technique they can review…so here it is:

Click here to watch a video about Arthroscopic Rotator Cuff Repair with Graft Reinforcement.

Click here to learn about Rotator cuff Repair – New Techniques and Challenges.

Rotator Cuff Graft Reinforcement Surgical Technique

  • 1 The principles are applicable to either the beach chair or modified lateral decubitus position, however, my preference is the modified lateral decubitus position (Fig. 1).
  • 2 After appropriate induction of regional and general anesthesia and prophylactic antibiotic administration, sterile preparation and draping is performed. Diagnostic arthroscopy with appropriate treatment of concurrent intra-articular sided shoulder pathology (frozen shoulder, biceps tear, labrum tear, subscapularis tear, etc.) is performed followed by subacromial arthroscopy with the arthroscope in the lateral portal (Fig. 2 and 3).
  • 3 An anterior and posterior portal, typically in line with the lateral border of the acromion, are established with 8.25 ID twist in cannulas (Fig. 3).
  • 4 Following subacromial debridement and treatment for other pathology as indicated (acromioplasty, distal clavicle resection, suprascapular nerve resection, etc.), the rotator cuff tear is debrided back to stable and viable tissue. The greater tuberosity footprint is also lightly abraded to restore bleeding bone. No attempt is made to decorticate the footprint (Fig 4).
  • 5 The size and pattern of the tear are measured and documented. Preliminary reduction maneuvers are performed to determine the best fit and pattern of the tear to restore equal tension throughout the rotator cuff (Fig. 5).
  • 6 Spinal needle localization is utilized to drill the initial tunnels at the anterior and posterior margins of the footprint immediately lateral to the articular margin using the Arthrotunneler instruments. These portals are percutaneous and typically located at the anterolateral and posterolateral corners of the acromion (Fig. 6).
  • 7 An anterolateral portal is established with spinal needle localization to place this distal and parallel to the tuberosity footprint (Fig. 7).
  • 8 An 8.25mm ID twist in cannula is typically placed through this portal first and then a 2.3mm beath pin is used to guide the Arthrotunneler into the subacromial space in order to minimize the perforations to the deltoid fascia (Fig. 8).
  • 9 Both Tunnels are completed and #2 Braided polyethylene suture of different colors is placed through each tunnel. These sutures are then passed through the rotator cuff at the location best determined to represent the reduced position to minimize the risk of medial tendon tears due to tension mismatch (Fig 9).
  • 10 Both lateral limbs of the tunnel sutures are retrieved through a percutaneous portal distal to the viewing portal to keep them out of the way. These are tagged with a clamp for safety. The medial trans-osseous sutures are also moved to percutaneous portals to keep them out of the way for the tension band repair (Fig 10).
  • 11 The rotator cuff repair is completed with multiply loaded suture anchors placed distal to the footprint. To maximize tension neutralization each suture is passed through the rotator cuff tendon and tied, prior to placing and tying the next one. This is continued, including placing side to side sutures as needed, until the entire rotator cuff tear has been repaired. Typically, this requires one or two triple loaded suture anchors based on the size and pattern of the rotator cuff tear (Fig. 11).
  • 12 The dimensions between the two medial trans-osseous sutures are recorded as well the distance from these sutures to the far lateral margin of the footprint. These dimensions are transferred to the graft on the back table (Fig. 12).
  • 13 Once the graft has been cut to size, the two medial trans-osseous suture limbs are brought out the antero-lateral twist-in cannula, keeping them parallel. Each is sutured in a locking running manner at its corresponding site on the graft, while maintaining tension on the graft with clamps (Fig 13).
  • 14 The two limbs are tied to each other creating a mattress configuration at the medial limb of the graft (Fig 14).
  • 15 The lateral limbs of the trans-osseous sutures are now tensioned and pulled steadily to deliver the graft into the subacromial space. The lateral limbs are retrieved to the antero-lateral cannula and tied over the bone bridge to provide uniform compression at the medial aspect of the rotator cuff footprint and stabilize the medial limb of the graft (Fig. 15).
  • 16 The graft is now draped and tension as required, typically with further sutures passed through the lateral limb of the graft and tied to saved sutures from the previously placed anchors or if needed more anchors are placed distally to stabilize the graft. This allows the graft to be loaded and tensioned uniformly while at the same time providing uniform compression and reinforcement for the rotator cuff (Fig 16).

Postoperative Care

The patient is placed in an abductor pillow type brace for 4 weeks postoperative, performing on gentle pendulum exercises several times each day. No passive motion, including pulleys, wall walks, etc. is utilized. At 4 weeks postoperative, the abductor pillow is discontinued and a supine passive stretching program is initiated focused on gentle multiple session of stretching daily prioritizing deltoid relaxation. No strengthening or upright above shoulder activities are initiated until 12 weeks postoperatively to maximize stress free tendon healing. After 12 weeks postoperatively, activities are progressed based on individualized clinical parameters.

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