3 Single-Row Undersurface All-Inside Rotator Cuff Repair

Ashleigh Elkins and George A.C. Murrell


We demonstrate an efficient approach to rotator cuff repair through a non-traditional intra-articular viewing approach. This undersurface technique is efficient, effective, and durable.

Keywords: single row, rotator cuff repair, all inside, undersurface

3.1 Patients Selected for Surgery

At our center, patients are referred for surgery if they have a symptomatic full thickness rotator cuff tear, or a partial thickness tear, which involves 50% or greater of the tendon?s thickness. The dimensions and thickness of the tear are determined based on preoperative ultrasound results. The ultrasounds are performed by an experienced musculoskeletal sonographer.

3.2 Patient Positioning

Patients are placed into the beach chair position. Anesthesia is in the form of an interscalene block with light sedation.

3.3 Patient Preparation

? Prophylactic antibiotics are administered prior to the procedure.

? Drapes are applied across the patient?s body.

? The shoulder, arm, and hand are prepared with an alcohol?iodine solution.

? A sterile drape sleeve is applied to the hand and forearm and secured with sterile bandaging.

? A sterile plastic drape is placed over the spider arm, and the forearm and hand are secured to the spider arm.

? Drapes are applied to cover the neck and torso regions.

? Iobans (3 M Australia, North Ryde, Australia) are applied over the shoulder region.

3.4 Posterior Portal Placement

? A sterile marking pen is used to mark the spine of the scapula, acromion, and acromioclavicular joint and the coracoid process.

? The posterolateral corner of the acromion is palpated and a line is drawn 1 cm inferior and 1 cm medial to this landmark.

? A scalpel is used (#11 blade) on the skin to create the posterior portal.

? The trocar is introduced, aimed toward the previously marked coracoid process.

? White balance is performed prior to introduction of the arthroscope.

? The arthroscope is introduced and the trocar is removed.

? Initial diagnostic arthroscopy is performed through this portal prior to the creation of the lateral portal (creation of this is described below).

3.5 Initial Diagnostic Shoulder Arthroscopy

? Via the posterior portal, initial diagnostic arthroscopy of the shoulder is performed (? Fig. 3.1a).

? The glenohumeral joint is inspected for concomitant shoulder pathologies.

? The glenoid labrum is evaluated for concomitant labral tears, including superior labrum anteroposterior tears, the glenoid and humeral head are inspected for bony Bankart lesions and Hill?Sachs lesions, the long head of biceps is evaluated for tears, and the capsule is assessed for evidence of adhesive capsulitis.

? Once the glenohumeral joint has been thoroughly assessed, the torn rotator cuff tendon is assessed from its undersurface.

? The head of the arthroscopic shaver is used as a reference point to measure the size of the tear, as there needs to be a minimum 5 mm defect in the supraspinatus tendon to permit passage of the shaver and sutures.

3.6 Creation of the Lateral Portal

? The position of the lateral portal is imperative to the success of the undersurface technique.

? The optimal position for the lateral portal for the undersurface technique is halfway between the anterior and posterior edges of the tear; this is so there is equal access to all aspects of the tendon.

? The position of the lateral portal is also important so that it allows the surgeon to place and deploy an anchor in the lateral part of the greater tuberosity (landing site).

? With the arthroscope remaining in the posterior portal, a spinal needle is inserted through the approximate position for the lateral portal, which is usually 1 cm inferior to the lateral margin of the acromion.

? The spinal needle is viewed using the arthroscope to determine whether the position is correct.

? The spinal needle needs to be angled in a way that sutures can be easily passed through the torn edges of the tendon, so that anchors can be placed perpendicular to the lateral margin of the supraspinatus footprint, and so that a shaver can debride the landing site.

? Once the appropriate position is identified with the spinal needle, a sterile surgical marker is used to mark the position of the portal and a #11 blade is used to create the portal. A cannula is not necessary when using the undersurface technique.

? The lateral portal is primarily used to insert the instruments necessary to perform the repair, as described below.

3.7 Preparation of the Tendon and Landing Site

? If the supraspinatus tear is of partial thickness, a #11 blade scalpel is introduced through the lateral portal and is used to convert the partial-thickness tear into a full-thickness tear.

? A 4.0- or 5.5-mm shaver (Stryker Endoscopy, San Jose, CA) is passed through the lateral portal and it is used to debride the torn edge of the tendon (? Fig. 3.1b). This is a light debridement as our aim is to retain the maximal amount of host tendon.


Fig. 3.1 Illustration of the undersurface repair technique. (a) Insertion of the arthroscope. (b) Preparation of the greater tuberosity landing site with an arthroscopic shaver. (c) Passing sutures through the edge of the torn tendon. (d) Use of a T-handled punch to prepare holes for the suture anchors. (e) Deployment of anchors into the holes on the greater tuberosity. (f) Completed repair with the torn tendon reattached to the greater tuberosity.

? After debridement of the tendon edge, the shaver is then used to debride the landing site of soft tissue. This process is also important for tendon-bone healing, as it induces bleeding.

3.8 Arthroscopic Suturing

? The Opus SmartStitch Suture Device (ArthroCare, Sydney, Australia) is used for suturing in the undersurface technique. This device assists placement of inverted mattress sutures.

? The SmartStitch Device is passed through the lateral portal. The edge of the torn tendon is grasped using the device and sutures are passed through the tendon (? Fig. 3.1c).

? If the tear is large enough to warrant a second suture, the second suture is usually placed posterior to the first suture.

3.9 Preparing and Deploying Suture Anchors

? A mallet is used to drive a T-handled punch into the landing site to create a hole for the suture anchor (? Fig. 3.1d).

? If more than one anchor is required to complete the repair, the first anchor site is placed laterally on the landing site and subsequent holes are created posteriorly, and often, more medially.

? After the creation of the holes for the anchors, sutures are then passed through the anchors (Opus Magnum, ArthroCare), which are then inserted into the holes (? Fig. 3.1e).

? The sutures are then tightened using the TensionLock winding mechanism on the Opus gun.

? The first suture is not tightened completely to allow for more room to visualize the insertion site for the second anchor. An early issue with the technique arose when the first suture was completely tightened, which made visualization of the next anchor difficult, and sometimes required conversion to a bursal-sided technique.

? Once all suture anchors are deployed, the sutures are tightened (? Video 3.1).

3.10 Closing

? Prior to closing the portals, the integrity of the repair is assessed arthroscopically by viewing the torn tendon from the undersurface while gently manipulating the arm (? Fig. 3.1f).


Video 3.1 Introduction and Rationale for the single-row undersurface all-inside rotator cuff repair.

? The arthroscope is removed, and the portals are closed using interrupted nylon sutures and Steri strips.

? Dressings are applied to the shoulder and the operated arm is placed in a sling with an abduction pillow (UltraSling, DJO Global, Dallas, TX).

3.11 Rehabilitation

? All patients who undergo an undersurface rotator cuff repair undergo a standardized rehabilitation protocol in the first 6 months postsurgery.

? Overhead activities are not permitted in the first 3 months postsurgery except for performing the prescribed exercises.

? The week prior to surgery, all patients attend a group education session conducted by a physiotherapist.

? For the first 6 weeks postsurgery, patients are instructed to wear a sling with a small abduction pillow to help reduce the tension on the repair.

? The rehabilitation protocol in the first 6 weeks consists of a number of gentle, passive range-of-motion exercises, including elbow flexion and extension range-of-motion exercises, grip-strengthening exercises, scapula-strengthening exercises, and pendulum exercises. No lifting is permitted in the first 6 weeks following surgery.

? From day 8 postoperatively, stick exercises are introduced to help improve range of motion in external and internal rotation, and shoulder flexion and extension.

? After the first 6 weeks, the patients are then reviewed by a physical therapist who then initiates isometric strengthening exercises in flexion, extension, adduction, and external rotation. Some further range-of-motion exercises are added, including flexion stretches using a wall, active supported external rotation, and towel stretches. At this stage, patients are permitted to lift up to 1 kg to chest height.

? The patients then undergo a review by the same physical therapist at 3 months postsurgery. At this stage, patients are permitted to perform overhead activities of less than 15 minutes duration. Active resistance exercises are introduced at this stage, which utilize therabands and light weights. Patients are permitted to lift between 2 and 5 kg.

3.12 Six-Month Review

? At 6 months, the patients are again reviewed by the surgeon. A comprehensive physical examination is performed to assess strength and range of motion.

? Patients also complete the L?Insalata questionnaire to determine patient-rated functionality and pain associated with the shoulder.

? An experienced musculoskeletal sonographer performs an ultrasound assessment to determine the integrity of the repair.

? If the repair is found to be intact on this assessment, the patient is usually encouraged to return to their pre-injury duties and activities.

3.13 Rationale for the Technique

? Rotator cuff tears are a common cause of shoulder pain and dysfunction, and re-tear is a common complication of rotator cuff repair.

? Most arthroscopic repair techniques include initial diagnostic arthroscopy of the glenohumeral joint to identify the torn rotator cuff and other concomitant shoulder pathologies. In standard rotator cuff repair techniques, the arthroscope is then repositioned in the subacromial space, and the tendon is approached from its bursal surface. This requires dissection or removal of the subacromial bursa to visualize the torn tendon and, often, concomitant acromioplasty. Because of the presence of the subacromial bursa, it can be difficult to visualize the torn tendon.

? Acromioplasty has long been performed routinely with rotator cuff repair. This is related to the theory of extrinsic subacromial impingement, which links the anatomical shape of the acromion to impingement and compression from the bursal side leading to abrasion and tearing of the rotator cuff. Recent studies suggest that there is little, if any, clinical benefit to performing an acromioplasty concurrently with rotator cuff repair; and performing an acromioplasty induces bleeding, which can further impair visualization.

? All arthroscopic rotator cuff repair methods are technically demanding, which is a key drawback. The technical difficulty of many arthroscopic repair methods is reflected by their long surgical duration. In 2006, rotator cuff repair had the longest operative time of all upper limb day procedures performed in the United States, at 73 minutes. Reported mean operative time for arthroscopic repair techniques range from 32 minutes to 113 minutes. Longer operating times are associated with higher economic costs, and potentially adverse clinical outcomes. Long operative times may be associated with infection and thromboembolic complications, and as suggested by some studies, possible increased risk of re-tear.

? Given these limitations of standard rotator cuff repair techniques, in 2008 we described an arthroscopic rotator cuff repair technique in which the entire repair was performed from within the glenohumeral joint. The torn tendon was repaired using a single row, tension band inverted mattress suture technique using knotless Opus Magnum suture anchors (ArthroCare). The technique utilizes advances in arthroscopic suture devices, such as the Opus SmartStitch Device and the Perfect Passer System (ArthroCare). These devices allow the surgeon to deploy sutures through the edge of the torn tendon in an inverted mattress configuration. The technique could be carried out while visualizing the tear from within the glenohumeral joint, without the need to perform an acromioplasty or dissect the subacromial bursa.

? Biomechanical studies of the undersurface repair technique showed that the technique produced good repair strength and good footprint compression.

? Our preliminary results in small cohorts of patients with this technique has been promising, with a markedly reduced operative time compared to the bursal-sided technique, and lower re-tear rates achieved with the technique (? Video 3.2).


Video 3.2 Demonstration of complete technique for the single-row undersurface all-inside rotator cuff repair.

3.14 Advantages of the Technique

? One of the key advantages of the undersurface technique compared to other techniques that approach the torn tendon from the bursal surface is its fast operative time. Results from a recent study of 1,000 cases found that the mean operative time for the undersurface technique is 16 minutes (unpublished data). Previous studies from our institute have shown that, on average, undersurface repairs are between 12 and 32 minutes faster to perform than bursal-sided repairs when using the same suture anchors. The reason why the undersurface repair is faster is because there is no need to perform a bursectomy or acromioplasty. Subacromial bursectomy and acromioplasty are time-consuming procedures. They also induce bleeding, which impairs visualization of the torn tendon and other structures within the glenohumeral joint. Shorter operative times are beneficial from an economic perspective as they result in lower operating room costs (? Video 3.3).

? Viewing from beneath the rotator cuff is also beneficial because it prevents inadvertent suturing of the long head of the biceps tendon, which may occur if viewing the rotator cuff tendon from its bursal surface.

? The re-tear rate for patients who have undergone an undersurface rotator cuff repair is low. A recent study performed at our institution analyzed 1,000 patients who underwent an undersurface repair, which revealed a re-tear rate of 8.5% (unpublished data). This is favorable given that re-tear rates quoted in the literature range between 15% and 90%. The re-tear rate for the undersurface repair is lower than the re-tear rate for the bursal-sided technique, with a study at our institution finding that the re-tear rate for the bursal-sided repair was 21%.

? Visualization of the torn tendon is optimized by the undersurface technique. Approaching the tendon from within the glenohumeral joint allows for greater visualization of the torn tendon and other shoulder structures, such as the long head of biceps tendon, the labrum, and the capsule, as the view is not obscured by the subacromial bursa.

? The undersurface technique is also relatively easy to perform. It is fairly easy to debride the tendon edge and the landing site with the arthroscope remaining in the glenohumeral joint and passing the arthroscopic shaver through a lateral portal. With the development of advanced suture-passing devices, such as the Opus Magnum SmartStitch Device and the Perfect Passer System (both from ArthroCare), it is also relatively straightforward to pass sutures through the edge of the torn tendon in an inverted mattress configuration. This suture configuration compresses the tendon onto the landing site in a tension band configuration and a greater time zero strength compared with simple sutures.


Video 3.3 Unedited 4-minute repair using the single-row undersurface all-inside technique.

? There is no need to perform an acromioplasty or subacromial decompression when the undersurface technique is performed. Although traditionally performed concomitantly with rotator cuff repair, recent evidence suggests that acromioplasty confers no additional benefit to the management of rotator cuff disease. Gartsman and O?Connor performed a randomized control trial comparing a group of patients that underwent only rotator cuff repair, and a second group that underwent rotator cuff repair and subacromial decompression. At 1-year follow-up, there was no difference in the American Shoulder and Elbow Surgeon?s score between the two groups. A meta-analysis found no statistically significant difference between patients undergoing isolated rotator cuff repair and those who undergo concomitant rotator cuff repair and subacromial decompression with respect to functional outcomes and rates of reoperation. However, acromioplasty may still be indicated in the management of patients with a type 3 acromion.

? Patient-reported outcomes following undersurface rotator cuff repair have also been promising. Patients have reported a reduced frequency and magnitude of shoulder pain, improvement in shoulder stiffness, improvement in overhead activities, as well as improved shoulder function at 6 months postsurgery. In this study, these parameters also demonstrated similar improvements in patients who underwent bursal-sided repairs. The key difference in terms of self-reported outcomes between the bursal-sided and undersurface repair groups were that patients who underwent bursal-sided repairs had more frequent pain during activity and more difficulty reaching behind the back than patients who underwent undersurface repair.

3.15 Disadvantages

? The main disadvantage of the undersurface rotator cuff repair technique is that occasionally it is necessary to complete the repair from the bursal side of the tendon. This is because it can be difficult to visualize the tendon landing site during placement of the final suture anchors toward the end of the repair. This is particularly a problem for larger tears requiring more suture anchors.

? With increasing experience with the technique, we have developed a method to avoid conversion to a bursal-sided repair. For larger tears, we often do not completely tighten the first anchor prior to deployment of the second anchor. The first anchor is subsequently tightened at the end of the repair. Subjectively, this has reduced the number of cases in which conversion to a bursal-sided repair is required. The main disadvantage of converting to a bursal-sided repair is inconvenience.

? The undersurface technique does not allow double-row fixation.

? Initially, we had concerns about the level of footprint contact achieved with the undersurface technique, especially with the arm in the abducted position. A biomechanical study of the technique demonstrated that there was good contact pressure at the footprint and that there was good repair strength.

3.16 Conclusion

The all-inside undersurface arthroscopic rotator cuff repair technique is a novel, fast, safe, and effective surgical technique that has produced promising results with respect to both surgical duration and the re-tear rate.

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