Sep
22
Rotator cuff surgery, explained by Ohio State Sports Medicine


Rotator cuff surgery, our patients are in
the upright, beach chair position. First we point out the AC joint. Next, we point out
the coracoid, an important landmark in shoulder surgery. Now we point out the anterior lateral
border of the acromion, the lateral border of the acromion, and next we palpate our glenohumeral
joint. Our fingers grasp the humeral head, we next confirm the joint line with a spinal
needle, and when it slides in easily, we use a scalpel, make our incision through which
we will insert the arthroscope. We use a metal, blunt cannula, and insert this through the
posterior capsule into the joint. We then place our camera through this cannula and
then we turn on our water supply. We are in the joint and immediately create an anterior
portal in the rotator interval with a spinal needle. We are lateral to the coracoid. We
make an incision and then insert our plastic cannula. You see the orange tip coming through
the tissue. We use this cannula to pass instruments in and out of the joint. We start our diagnostic
exam of the shoulder. Humeral head is to the right and the glenoid is to the left. This
is the anterior labrum, a little tattered, but not detached. We slide into the axillary
pouch. We then bring our camera up the back of the glenoid, and now we visualize the long
head of the biceps. We again focus on our anterior labrum, and just to the right the
thick band of tissue is the middle glenohumeral ligament. Beneath the cannula was a subscapularis.
We next use our shaver to debride and smooth the rough edges of the anterior labrum, which
showed some degenerative tearing. We next maneuver our shaver above the long head of
the biceps to the area of the rotator cuff tear. We pause here. The anterior supraspinatus
is torn and flipped immediately into the glenohumeral joint. These torn edges are hypovascular and
need to be debrided. We also need to remove these torn edges to better evaluate our tendon
tear. Now, as we continue with the shaver, you clearly see the defect in the tendon much
better as we progress. It is not attached to the footprint of the
greater tuberosity. You clearly see this area, and a little more debridement with the shaver
will help us completely prepare the undersurface of the rotator cuff tear. We pause on the
tear and you see the dark area to the right is a small, crescent shaped rotator cuff tear,
not attached. We next move to the subacromial space and place the arthroscope in the space
and we create a lateral portal. We insert the same cannula and our shaver to perform
a bursectomy. We begin our bursectomy. The fluffy white tissue is the bursa, which we
need to clean out in order to visualize. Just above our shaver is the shiny white coracoacromial
ligament, which is attaching to the anterior lateral border of the acromion. This is the
location of a spur. We next bring our cautery device, which ablates soft tissue and is also
capable of stopping any bleeding from the bursa. Our shaver is then used again in the
lateral gutter of the subacromial space. We must clear out this bursal tissue, which is
covering the bursal side of our rotator cuff tear. To the right of our shaver, the pink
tissue is our deltoid. When our bursectomy is complete, we see our small rotator cuff
tear. We must then prepare the edges of the tear and the underlying bone for the rotator
cuff repair. The shaver is actually inside the tear, in the glenohumeral joint, and then
lightly removing soft tissue from the underlying bone of the greater tuberosity footprint.
We need ablated surface for the tendon to heal to. Here is a nice view of our one
centimeter, supraspinatus tear, the underlying yellow surface is the bone of the tuberosity.
We must now localize the correct angle of approach for our anchor. In the subacromial
space, we confirm the spinal needle location, we make a nick in the skin and insert our
punch to make a pilot hole for the anchor. We find the correct spot in the tuberosity,
and then we mallet this punch down to the black line that lets us now how far to go.
Once our punch is all the way down, we insert a tap to prepare the bone for the anchor.
The small yellow globules you see are fat from the bone. Once the tap is seated, we
can remove the tap knowing our bone is prepared, and we are ready to place our bioabsorbable
anchor which you see here. We place this at the same angle of approach into our prepared
pilot hole. We seat the anchor at the black line again, and then we pull on these sutures
to assure the anchor is well seated in the bone. We next must create an accessory portal
again with a spinal needle, make a skin incision, and then we insert another slightly larger
black cannula you see here. We then use a suture retriever and retrieve our first suture
through the cannula. This is our suture lasso, a metal device for shuttling suture through
the tendon. We place it in the subacromial space and pierce the rotator cuff tendon medial
to the tear, assuring a good healthy bite of tendon. We come out through the tear with
the lasso, which is cannulated, and produces a wire loop which we take out our accessory
anterior portal. The suture awaits, we place this in the loop, and we shuttle this back
through the rotator cuff tendon as you see here. We again use our retriever to take a
blue and a white suture out our anterior cannula again. We repeat the same step with our suture
lasso, pulling onto the edge of the tendon for tension, we pierce the tendon medical
to the tear, produce our lasso, and again we retrieve this lasso loop out our cannula.
We shuttle our two sutures through the tendon. Our grasper retrieves the last white suture
and takes it out our anterior cannula. We again pierce the tendon medial to the tear, posterior
to our other sutures. We produce our lasso and pull this again out our anterior cannula,
we put the suture through the loop, you see this here outside the body, and then we pull
the suture through the loop and again into the subacromial space, shuttling this through
our rotator cuff tendon. All four sutures are now through the tendon, and we must grasp
corresponding sutures to tie our knot. Here we took two white sutures, outside the cannula
we are tying a special sliding knot called the SMC knot. By pulling on one end of the
suture, we know slide down into the subacromial space our knot, and our knot pusher device
pushes this knot firmly down onto the rotator cuff, indenting the cuff nicely. We tie half
hitches, which are multiple knots on top of this knot, you see us tying outside the cannula,
and this will really tighten the knot down and cinch down the rotator cuff down to the
anchor. When we are complete, we retrieve our blue sutures as we have now placed the
white sutures in another cannula to prevent tangling. Once we have pulled these sutures
outside the body, we again tie our same knot. You see our knot pusher sliding the suture
down to cinch the knot down firmly, which is quite important. We next prepare for our
lateral anchors. We need one of each suture, one blue and one white, thus we retrieve these
to load outside the body into our PushLock anchors, which as you will see will firmly
pull the tendon down over the footprint of the greater tuberosity. We seat these anchors
in the good lateral bone of the greater tuberosity. Our punch feels and confirms the bone is solid,
and we make a pilot hole as you see here. We then place the loaded PushLock anchor
into the pilot hole. Before we seat the anchor, we pull the slack out of our sutures to assure
the tendon is snug down. When we are pleased, we seat our anchor, as you see, and we cut
the ends of the suture. We then repeat this step again with a next set of sutures, pulling
them out the lateral cannula. Here you see us loading them into the eyelet of the PushLock device. We again make a pilot hole in the lateral cortex with a punch, a good one
centimeter posterior to our other PushLock. We then place our anchor into this hole, pull
the slack out of our sutures, and when we are satisfied, we seat our PushLock anchor.
These anchors give us an interference fit for the sutures laterally. They effectively
create double row rotator cuff repair without needing to place more anchors in the small
greater tuberosity footprint. Here’s our final repair viewed from the lateral portal. See
how the sutures are all tied medially in the tendon and the ends are pulled over the lateral
aspect of the tendon to this lateral row of anchors. The tendon is pulled flush over the
greater tuberosity footprint increasing the surface area for tendon healing to bone. We
internally and externally rotate the arm and you can see a solid repair that is quite stable.