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Shoulder Videos: Rotator Cuff
Superior Capsule Reconstruction Using an Acellular Dermal Matrix Allograft Combined With Remnant Tendon Augmentation for Irreparable Rotator Cuff Tear
Graft fixation sites on the greater tuberosity and the superior glenoid for superior capsule reconstruction (SCR) are prone to graft failure. The graft fixation procedure on the superior glenoid is challenging due to the limited working space, narrow graft attachment site, and difficulties in suture management. This technical note introduces the surgical technique of SCR using an acellular dermal matrix allograft combined with remnant tendon augmentation to enhance graft healing and the suture management technique to prevent suture tangling for the treatment of irreparable rotator cuff tear.Modified Double-Pulley And Rip-Stop Suture Bridge Technique In Arthroscopic Rotator Cuff Repair
Numerous techniques have been formulated for increasing the tendon–bone contact area and for providing a better healing environment for the tendon in cases of rotator cuff tear. An ideal rotator cuff repair maximizes the tendon–bone interface and provides the rotator cuff with sufficient biomechanical strength for it to withstand a high load. In this article, we propose a technique with the advantages of both the double-pulley and the rip-stop suture-bridge techniques, which increases the pressurized contact area along the medial row, achieves higher failure loads than non-rip-stop techniques, and reduces tendon cut-through.Single Portal Technique for Subscapularis Tendon Repair
The fast and steady development of arthroscopy techniques in the last couple of decades led to a drastic increase of arthroscopic rotator cuff repairs over the open procedure. Supraspinatus tears are the most common of all, but the subscapularis tendon tear is a more common injury than expected. Most of the time it presents as a partial tear or is associated with a subsequent rotator cuff tendon injury, especially the supraspinatus. Nowadays, the standard procedure to repair the subscapularis tendon is performed arthroscopically, even though a real superior result over the open repair it is yet to be reported.Arthroscopic Massive Rotator Cuff Repair and Techniques for Mobilization
Massive rotator cuff tears, as classified by size or tendon involvement, are challenging to repair due to scarring, retraction of the tendons, and difficult visualization. Left untreated, these injuries can lead to fatty infiltration and reduced acromiohumeral distance that precludes future repair. The high rate of failure in these patients often impedes an anatomical repair. However, advanced mobilization techniques of the supraspinatus help facilitate a reduction of an otherwise irreparable tear.Arthroscopic Repair of an Isolated Subscapularis Tendon Rupture in an Adolescent Patient
Arthroscopic repair of an isolated subscapularis tendon rupture has been previously described in the adult population; however, the technique has yet to be described in a pediatric patient. In this Technical Note, we describe an arthroscopic repair of an isolated subscapularis tendon rupture with concomitant mini-open suprapectoral biceps tenodesis in an adolescent patient. Standard anterior and posterior portals are established with an accessory portal in the anterosuperior angle of the acromion.Long Head Biceps Tendon—Natural Patch for Massive Irreparable Rotator Cuff Tears
Despite the development in shoulder surgery, massive irreparable rotator cuff tears still remain challenging for orthopaedic surgeons. Many surgical methods are addressed to this kind of pathology, but each of them has its own limitations. We decided to fuse the ideas of superior capsular reconstruction, “GraftJacket” technique, and partial rotator cuff repair. In this way, the technique using the long head biceps tendon simultaneously as a vascularized bridge between rotator cuff remnants and greater tubercle and as a depressor for the humeral head was created.Double-Row Repair Technique for Bursal-Sided Partial-Thickness Rotator Cuff Tears
Rotator cuff pathology is a common cause of shoulder pain in the athletic and general population. Partial-thickness rotator cuff tears (PTRCT) are commonly encountered and can be bursal-sided, articular-sided, or intratendinous. Various techniques exist for the repair of bursal-sided PTRCTs. The 2 main distinctions when addressing these lesions include tear completion versus preservation of the intact fibers, and single- versus double-row suture anchor fixation. We present our method for addressing bursal-sided PTRCTs using an in situ repair technique with double-row suture anchors.Arthroscopic-Assisted Pectoralis Minor Transfer for Irreparable Anterosuperior Massive Rotator Cuff Tear
An irreparable anterosuperior massive rotator cuff tear with an irreparable subscapularis tear is not common; however, once symptomatic, it would become a challenging situation. Tendon transfer is a choice and the pectoralis major is a commonly selected graft source. However, there are theoretical concerns over its use: high invasiveness and low reproducibility, different force vector from the subscapularis, unsuitability for the arthroscopic modification, and difficulty in conversion to the reverse shoulder arthroplasty due to adhesions and scar formation in the anterior shoulder.Arthroscopic In Situ Superior Capsular Reconstruction Using the Long Head of the Biceps Tendon
Large to massive rotator cuff tears are challenging to repair, although there are several options for dealing with them. Among them, superior capsular reconstruction was recently introduced as an effective procedure for retaining the static stability of the shoulder joint and preventing the progression to cuff tear arthropathy. The purpose of this technique-based article is to describe a surgical option, called arthroscopic in situ superior capsular reconstruction, for large to massive rotator cuff tears using the long head of the biceps tendon.Latissimus Dorsi Tendon Transfer With Acromial Osteotomy for Massive Irreparable Rotator Cuff Tear
Latissimus dorsi tendon transfer is an effective option for young and active patients with massive irreparable posterosuperior rotator cuff tears and intact subscapularis tendon. This approach has been shown to relieve pain and improve shoulder function in both the short and long term. We describe a surgical technique using an acromial osteotomy to better expose the greater tuberosity for the tendon transfer without disrupting the deltoid muscle. The latissimus dorsi tendon is reinforced with a human dermal collagen matrix (GraftJacket; Wright Medical Group) for additional augmentation of the muscle to gain more excursion for the tendon transfer to the greater tuberosity.All–Extra-articular Repair of Anterosuperior Rotator Cuff Tears
Anterosuperior rotator cuff tears involve the subscapularis tendon, supraspinatus tendon, and rotator interval. The long head of the biceps is usually affected and unstable in these complex lesions. Arthroscopic repair of anterosuperior rotator cuff tears often consists of 2 different procedures. Whereas the subscapularis tendon is reconstructed under intra-articular visualization, the supraspinatus tendon is reconstructed under extra-articular visualization. The rotator interval is often sacrificed to improve visualization and instrumentation.An Arthroscopic Knotless Technique for Anatomical Restoration of the Rotator Cuff and Superior Capsule: The Double-Layer Cinch Bridge
Rotator cuff repairs are the most common procedures in shoulder surgery, but still show long-term retear rates of up to 70%. Nonanatomic reconstruction is one possible cause of repair failure. The rotator cuff histologically consists of 5 separate layers of which 2 are macroscopically identifiable: the superior or tendinous layer and the inferior or capsule-ligamentous layer. In case of rotator cuff tears, these layers are often retracted to different degrees. The intraoperative detectable prevalence of rotator cuff delamination reaches up to 85%.Knotless Suture Bridge Technique in High-Grade Bursal-Sided Rotator Cuff Tears. Is This The Way Forward?
We present our technique in managing high-grade bursal-sided rotator cuff tears. In this technique, the remaining intact cuff tissue is not sacrificed. The suture bridge technique is used to uniformly tension the torn tissue to the rotator cuff footprint. No knots are tied on the rotator cuff to minimize the tension on the cuff. The sutures are then anchored on the lateral cortex of the humerus. This technique allows repair with minimum tension while preserving the original length of the rotator cuff.Anterior Capsule Reconstruction for Irreparable Subscapularis Tears
A subscapularis complete tear presents its own challenges in management. The glenohumeral biomechanics and force couple are reliant on a competent and functioning subscapularis muscle. An irreparable subscapularis makes those same challenges even more difficult to address. Traditionally, this problem has been addressed with tendon transfers, including pectoralis major or latissimus dorsi. These techniques can alter the ideal biomechanics of the shoulder and have high rates or failure. Iliotibial autograft or tibialis anterior have also been wrought with high failure rates.Arthroscopic Repair of Medial Transtendinous Rotator Cuff Tears
Rotator cuff tears are extremely common in the adult population, and medial transtendinous rotator cuff tears, although rare, have recently been reported in the literature. These tears are almost always traumatic, which is a common indication for surgical management. It is necessary to consider these tears as a distinct subset when planning for rotator cuff repair because traditional repair techniques would overtension the tendon, increasing the risk for failure of the repair. The objective of this Technical Note is to describe an arthroscopic repair technique for these tears that avoids overtensioning the rotator cuff while still using repair techniques that are familiar to the arthroscopic shoulder surgeon.An Arthroscopic Humeral Medializing Repair of the Supraspinatus
Posterosuperior repair of the rotator cuff is one of the most frequently performed surgical procedures in the shoulder. Its aim is to fix the tendon back to the bone to restore anatomy, improve shoulder function, and prevent progression of cuff tear arthropathy and attendant muscle degeneration. Despite technical advances in this procedure, in some cases, the tendon cannot be fixed back to the footprint without excessive tension on the repair. In young patients or in patients with low-grade muscle atrophy and fatty degeneration (Goutallier grade 1 or 2), it is mandatory to attempt fixation of the tendon to restore functional anatomy and prevent further muscle degeneration.Arthroscopic Repair of Massive Subscapularis and Supraspinatus Tear by Double-Row Knotless Technique
Subscapularis is the most powerful muscle in the rotator cuff. A steep learning curve and constrained space anteriorly make the repair difficult. In massive tears of the rotator cuff, repair of the subscapularis initially makes the massive supraspinatus tear repairable. We present our technique to repair subscapularis and supraspinatus tear by double-row anchors in a knotless and tension-free manner. This technique can be done in partial or full-thickness tears of the upper subscapularis.Middle Glenohumeral Ligament Abrasion Causing Upper Subscapularis Tear
The middle glenohumeral ligament (MGHL) typically contributes partially to the anterior stability of the shoulder. In a very limited number of cases, the MGHL can cause abrasion on the upper edge of the subscapularis causing persistent pain symptoms for patients. The condition is exacerbated by internal rotation of the arm. In this Technical Note, we describe this entity and call it the SAM lesion (Subscapularis Abrasion from the MGHL). We present a technique of addressing this lesion.Superior Capsular Reconstruction With Superimposition of Rotator Cuff Repair for Massive Rotator Cuff Tear
Massive rotator cuff tears are particularly challenging to treat and severely limit the function of the shoulder. Compared with a small rotator cuff tear, massive tears are more unpredictable and usually present with low tendon quality. When performing an anatomical repair of the rotator cuff, the surgical treatment is often associated with failure of the construct. An alternative procedure that can be performed in the setting of a massive tear is superior capsular reconstruction (SCR), using an autograft or allograft.Arthroscopic Shoelace Side-to-Side Repair Technique Using Ultratape for the Treatment of Longitudinal Midsubstance Rotator Cuff Tears
Shoulder arthroscopy is a promising tool for assessing and treating patients with a rotator cuff tear. Arthroscopic rotator cuff repair with suture anchor fixation such as the single-row, double-row, and suture bridge technique are popular procedures that can provide excellent clinical outcomes. On the other hand, longitudinal midsubstance, U-shape, or L-shape tears may benefit more from a side-to-side/margin convergence technique. Despite following the standard side-to-side/margin convergence technique, we continue to see disruption at the site of side-to-side suture margin even with strong sutures.The “Parachute” Technique: A Simple and Effective Single-Row Procedure to Achieve an Increased Contact Area Between the Cuff-Tendon and Its Footprint
Many techniques of arthroscopic rotator cuff repair have been described. No significant differences in clinical outcomes or rerupture rates have been observed when comparing single-row with double-row methods. Not all single- and double-row repairs are the same. The details of the technique used are crucial. It has been shown that the suture-tendon interface is the weakest point of the reconstruction. Therefore, the biomechanical properties of rotator cuff repairs might be influenced more by the suture configuration than by the number of anchors or by the number of rows involved.Anterior Capsule Reconstruction Technique With an Acellular Dermal Allograft
An irreparable subscapularis may have a debilitating influence on glenohumeral joint biomechanics. Traditional treatment approaches are focused on tendon transfers, among which the most popular are pectoralis major and latissimus dorsi transfers. However, these techniques present significant retear rates, possible nerve injuries, and altered biomechanics. Other techniques like tibialis anterior or iliotibial autograft grafting also have many reported failures. We describe an all-arthroscopic anterior capsule reconstruction technique with an acellular dermal graft.Revision of Failed Rotator Cuff Reconstruction With a Large Humeral Head Cyst
A revision rotator cuff repair is a technically challenging surgical procedure. This can be further complicated by the presence of poor quality of the cuff tissue, as well as a large greater tuberosity cyst, typically located at the rotator cuff footprint. This Technical Note discusses the surgical approach to deal with a revision rotator cuff tear with a large humeral head cyst. This described arthroscopic technique is performed in a single-stage procedure using a human dermal allograft (GraftJacket) for augmentation.“Double-Row Rip-Stop” Technique for Arthroscopic Rotator Cuff Repair
Rotator cuff repair depends on both the fixation strength of the chosen repair construct and the local healing response of the repaired tissue. Among a growing discussion surrounding the superiority of one surgical technique over another, the surgeon's ability to complete a rotator cuff repair with technical acuity in a timely manner remains paramount. Double-row repairs as well as rip-stop configurations have been proposed to limit failures found after arthroscopic rotator cuff repairs. Implementation of both techniques during arthroscopic shoulder surgery may represent a technical challenge for the average orthopaedist.Arthroscopic Rotator Cuff Repair With Mini-open Subpectoral Biceps Tenodesis
With a range of tear characteristics such as chronicity, degree of fatty atrophy, and number of tendons involved as well as varying patient-specific characteristics including age, injury mechanism, and expectations after treatment to consider, proper and successful treatment of a rotator cuff tear is multifactorial and, consequently, challenging. Although conservative management of a rotator cuff tear may be successful, a more severe tear with involvement of more tendons may warrant surgical intervention.
