Massive rotator cuff tears can be a challenge to repair and to heal. Factors that play into whether a massive tear is repairable or not include the degree of mobilization to return the tendon to the footprint, tissue quality, and size of the tear. We propose basic tendon releases and the use of multiple traction sutures placed in the tendon in a luggage tag fashion for increased mobilization of the tendon. The traction sutures placed at the anterior leading edge of the supraspinatus tendon are then placed into an anchor laterally for provisional reduction of the anterior leading edge of the tear. This subsequently reduces the size of the tear to be repaired and a simple double-row SpeedBridge technique is then applied posterior to the reducing anchor allowing for a more tension-free repair. A bioinductive bovine augment patch is arthroscopically placed to aid in enhanced healing of tendon to bone.
Keywords: bioinductive, bovine patch, double-row repair, massive rotator cuff tear, tendon healing
? The patient is placed in the lateral decubitus position.
? A sandbag is used to aid in positioning.
? Care is taken to pad all bony prominences.
? An axillary roll is placed underneath the axilla for padded protection.
? Surgical preparation is done with chlorhexidine solution.
? The surgical extremity is placed in a padded lateral arm positioner (? Fig. 6.1a,b).
? A standard posterior viewing portal is made (? Fig. 6.2).
? An anterior portal is then made through the rotator interval using a spinal needle to determine angle and position of the portal under direct visualization prior to incision.
? A midlateral portal is made for subacromial access, two digits from the lateral edge of the acromion in a horizontal fashion.
? A posterolateral portal (portal of Wilmington) is made for viewing the subacromial space during rotator cuff repair. This frees up the posterior portal for suture management.
Fig. 6.1 (a) Lateral positioning of a left shoulder using an arm holder in 45 of abduction and 20?30 of forward flexion. (b) View from where the main surgeon stands. Notice where we like to place our instruments on the Mayo stand and the monitor.
Fig. 6.2 Marking of our usual portals. We generally go about two fingerbreadths off the acromion for both our midlateral and posterolateral portals.
? A standard posterior viewing portal is made.
? Thorough assessment of intraarticular pathology is performed.
? A standard anterior viewing portal is made, and a 7-mm instrument cannula is placed (Arthrex, Naples, FL) under visualization.
? Debridement, synovectomy, removal of loose bodies, labral repair, and/or biceps tenotomy are made at this time as needed. We perform a biceps tenodesis if the patient has preoperative clinical bicipital symptoms.
Fig. 6.3 A view of the subacromial space from the posterior portal showing the extent of our rotator cuff tear.
? Access the subacromial space from the posterior portal.
? Develop the lateral portal, a two-finger breadth width from the lateral edge of the acromion. This is midlateral.
? Perform a meticulous subacromial bursectomy. We do not routinely perform a subacromial decompression.
? Complete rotator cuff exposure is key. This is performed with both shaver and electrocautery.
? Assess the rotator cuff for tear pattern and size (? Fig. 6.3).
? For access to the posterior rotator cuff, develop a posterolateral working portal with the aid of a spinal needle.
? Maintain adequate spacing between the lateral portal and posterior portal (? Fig. 6.4).
? Place a PassPort Cannula (Arthrex) in the lateral portal for suture shuttling and an instrument cannula in the posterolateral portal.
? Debride any remnant cuff tissue from the footprint using an arthroscopic wand and shaver.
? Use a bur instrument to gently decorticate the bone.
? An assistant should internally and externally rotate the arm posteriorly and anteriorly, respectively (? Fig. 6.4).
Use a soft tissue elevator to release adhered rotator cuff tissue from the superior glenoid neck as well as above the rotator cuff in the subacromial space.
? Place a FiberLink suture (Arthrex) in a luggage tag fashion in the rotator cuff at the anterior leading edge of the supraspinatus. If the posterior aspect of the tendon tear also needs to be tagged, an additional suture may be needed (? Fig. 6.5).
Fig. 6.4 Position of our posterior portal for the arthroscope and the midlateral working portal while in the subacromial space.