principles of arthroscopic rotator cuff repair edward tillett, m.d. department of orthopedic surgery...
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Principles of Arthroscopic Principles of Arthroscopic Rotator Cuff RepairRotator Cuff Repair
Edward Tillett, M.D.Department of Orthopedic Surgery University of Louisville
Principles of Arthroscopic Principles of Arthroscopic Rotator Cuff RepairRotator Cuff Repair
Adequate VisualizationAdequate Visualization
Rotator cuff preparation prior to repairRotator cuff preparation prior to repair
Appropriate portal placement for suture Appropriate portal placement for suture passage and suture anchor placementpassage and suture anchor placement
Secure knot tying Secure knot tying
Adequate VisualizationAdequate Visualization
Techniques to minimize bleedingTechniques to minimize bleeding
Adequate subacromial bursectomyAdequate subacromial bursectomy
Subacromial decompressionSubacromial decompression
Techniques to Minimize BleedingTechniques to Minimize Bleeding
Adequate distension of subacromial spaceAdequate distension of subacromial space Gravity inflow or arthroscopic pumpGravity inflow or arthroscopic pump
Anaesthesia to keep blood pressure Anaesthesia to keep blood pressure normotensive or belownormotensive or below
Adequate Subacromial BursectomyAdequate Subacromial Bursectomy
Anatomy of subacromial bursaAnatomy of subacromial bursa
Adequate Subacromial BursectomyAdequate Subacromial Bursectomy
The bursectomy needs to be anterior, The bursectomy needs to be anterior, posterior, distal. posterior, distal. Must see the entire rotator cuffMust see the entire rotator cuff Must see the insertion of the rotator cuff onto Must see the insertion of the rotator cuff onto
greater tuberositygreater tuberosity
Resection: Camera and shaver must be Resection: Camera and shaver must be switched between posterior and lateral switched between posterior and lateral portal portal
Portals for Subacromial Portals for Subacromial BursectomyBursectomy
Posterior Portal: Posterior Portal: standard posterior portal used for standard posterior portal used for
glenohumeral joint inspection: 2cm distal and glenohumeral joint inspection: 2cm distal and medial to posterolateral border of acromiummedial to posterolateral border of acromium
Lateral Portal:Lateral Portal: 3 fingerbreadths distal from the anterolateral 3 fingerbreadths distal from the anterolateral
border of the acromiumborder of the acromium
Portals for Subacromial BursectomyPortals for Subacromial Bursectomy
Arthroscopic VisualizationArthroscopic Visualization
Anterior subacromial bursaAnterior subacromial bursa
Posterior subacromial bursaPosterior subacromial bursa
Subacromial DecompressionSubacromial Decompression(if necessary)(if necessary)
Cutting Block TechniqueCutting Block Technique
Camera in lateral portalCamera in lateral portal
Shaver in posterior portal Shaver in posterior portal
Prepare Tear for RepairPrepare Tear for Repair
Identify type of rotator cuff tearIdentify type of rotator cuff tear
Mobilize tear through soft tissue releasesMobilize tear through soft tissue releases
Mobilize tear through marginal Mobilize tear through marginal convergence suturesconvergence sutures
Identify Rotator Cuff TearIdentify Rotator Cuff Tear
U-shaped tearU-shaped tear
Crescentic-shaped repairCrescentic-shaped repair
L-shaped tearL-shaped tear
Mobilize Tear through Soft Tissue Mobilize Tear through Soft Tissue ReleasesReleases
Resect soft tissue above and below tearResect soft tissue above and below tear
Release of coracohumeral ligament at Release of coracohumeral ligament at base of coracoidbase of coracoid
Release of infraspinatus/supraspinatus Release of infraspinatus/supraspinatus interval in line with scapular spineinterval in line with scapular spine
Mobilize Rotator Cuff through Mobilize Rotator Cuff through Marginal Convergence SuturesMarginal Convergence Sutures
Appropriate for U-shaped tearAppropriate for U-shaped tear
Principle is to do a side to side tendon Principle is to do a side to side tendon repair in an anterior to posterior directionrepair in an anterior to posterior direction Lateralize the tendon towards the greater Lateralize the tendon towards the greater
tuberosity tuberosity Take tension off the repair to the greater Take tension off the repair to the greater
tuberositytuberosity
Mobilize Rotator Cuff through Mobilize Rotator Cuff through Marginal Convergence SuturesMarginal Convergence Sutures
Mobilize Rotator Cuff through Mobilize Rotator Cuff through Marginal Convergence SuturesMarginal Convergence Sutures
Portals for Suture TechniquePortals for Suture Technique
Portal location is about periphery of Portal location is about periphery of acromium acromium
Dependent upon the location of the tear Dependent upon the location of the tear and the type of suture retrieval device and the type of suture retrieval device being used.being used.
Technique of Suture Anchor Technique of Suture Anchor PlacementPlacement
Ideal angle of suture anchor is 45Ideal angle of suture anchor is 45° relative ° relative to the long axis of the humerus.to the long axis of the humerus.
Placement of suture anchor is as close to Placement of suture anchor is as close to greater tuberosity as possible.greater tuberosity as possible. Should not repair the tendon under too much Should not repair the tendon under too much
pressure, therefore, a medialized location pressure, therefore, a medialized location may be necessary.may be necessary.
Technique of Suture Anchor Technique of Suture Anchor PlacementPlacement
Sometimes, the medial and lateral Sometimes, the medial and lateral attachments of the rotator cuff are both attachments of the rotator cuff are both repaired (double-row repair)repaired (double-row repair)
Portals for Suture Anchor Portals for Suture Anchor PlacementPlacement
Portal placement is verified with a spinal Portal placement is verified with a spinal needleneedle
The needle is directed at 45The needle is directed at 45° to the ° to the humerus and close to the tendon tear humerus and close to the tendon tear where the repair is necessarywhere the repair is necessary
The site of portal location varies about the The site of portal location varies about the rim of the anterolateral aspect of the rim of the anterolateral aspect of the acromium. acromium.
Portals for Suture Anchor Portals for Suture Anchor PlacementPlacement
Secure Knot TyingSecure Knot Tying
Sliding or half hitch knotsSliding or half hitch knots
Knot SecurityKnot Security
Loop SecurityLoop Security
Example of Arthroscopic Rotator Example of Arthroscopic Rotator Cuff RepairCuff Repair