2 SCOI Row Rotator Cuff Repair?A Medial Row, Tension-Free, Triple-Loaded, Crimson Duvet?Augmented Rotator Cuff Repair

Eric Tannenbaum, John Taylor, Stephen Snyder, and Michael Bahk

Summary

The Southern California Orthopedic Institute (SCOI) row rotator cuff repair technique involves a medial row, tension-free, triple-loaded, crimson duvet?augmented construct. This chapter describes a rotator cuff repair with a 95% healing rate for small-to-medium-sized rotator cuff tears and emphasizes the above key elements as part of the repair. This chapter highlights pertinent supportive literature. We also describe the lateral decubitus position, standard portals (posterior, anterior midglenoid, lateral, percutaneous anchor portals), tricks for bursectomy, how to perform the ?perfect decompression,? rotator cuff repair techniques and rehabilitation processes, and typical timeline.

Keywords: rotator cuff repair, rotator cuff tear, SCOI row, single row

2.1 Patient Positioning

? Following intubation, two pillows are placed between the legs and two between the down leg and the operative table to limit pressure on the bony prominences. All other bony prominences are well padded with foam padding.

? On anesthesia?s count, the patient is rolled into the lateral decubitus position supported with a 3-foot-long Vacupak ?beanbag? size 32 (Olympic Medical, Seattle, WA). The knees and hips are flexed to a comfortable position.

? A gel axillary roll is placed under the patient?s lower axilla to prevent injury to the brachial plexus throughout the case.

? A foam head-and-neck support with a section cutout for the patient?s ear is utilized by the anesthesiologist to place the head in a neutral position.

? Prior to suctioning, the bean bag is molded around the torso to maintain the patient in the lateral position with a 20� posterior tilt.

? Sequential compression devices are applied to bilateral lower extremities to mitigate risks of intraoperative deep vein thrombosis.

? The operating room table is rotated 45� posterior, allowing room for the surgeon to stand at the patient?s head.

? Prior to placement in traction, the patient?s shoulder is examined under anesthesia for range of motion and ligamentous laxity.

? A 3-point shoulder traction unit is attached to the inferior end of the operating room table on the contralateral side using a Clark rail attachment.

? The patient?s hand/forearm is placed between two foam pads and wrapped with Coban.

? A stockinette is rolled over the foam padding. The distal end of the stockinet is the folded back onto the arm, leaving a 2-inch loop at the distal end of the extremity and then wrapped again with Coban.

? A metal S-hook or carabiner is used to connect the arm to the traction boom and 10?15 lb of traction is placed with the arm in approximately 70� of abduction and 10� of forward flexion (the glenohumeral position). Later in the case, the weights will be changed to the other cable when placing the arm into the bursoscopy position with 15� of abduction and 5� of forward flexion.

? The arm is then prepped in the usual sterile fashion with Chloraprep.

? A U-drape is placed around the shoulder starting from the neck. A rectangular drape is applied above the shoulder to connect legs of the U-drape and finally arthroscopy drapes are placed.

? A sterile green towel is wrapped around the arm paying careful attention not to touch the nonsterile extremity and contaminate the surgical field. This is wrapped with sterile Coban using the tubing of the Coban to create a quiver for the arthroscopic instruments (switching sticks, graspers, etc.).

2.2 Portal Placement

The bony landmarks are traced out along margins of the clavicle, acromion, and scapular spine. An orientation line is drawn from the posterior edge of the acromioclavicular (AC) joint extending laterally down the arm approximately 5 cm perpendicular to the lateral border of the acromion.

2.2.1 Posterior Midglenoid Portal (PMGP)

? The posterior shoulder anatomy is palpated and the humeral head is balloted, rocking it anterior to posterior to sense the location of the joint line. The posterior midglenoid portal is typically created 2?3 cm inferior and 1?2 cm medial from the posterolateral acromial edge.

? A small stab incision is made through the skin in this location using a #11 knife blade in the direction of the skin lines. Only the skin is incised.

? Insert the arthroscopic cannula with a tapered-tip obturator through the skin/muscle until the humeral head is palpated with the tip.

? Direct the cannula medial to the humeral head aiming to the center of the glenohumeral joint. The arthroscope is oriented with the glenoid inferior or parallel to floor.

2.2.2 Anterior Midglenoid Portal (AMGP)

? This may be done using an inside-out technique or an outside-in technique. For the purposes of this chapter, we utilized the outside-in technique for our anterior portal creation.

? Viewing with the arthroscope from the posterior portal, a spinal needle is placed approximately 3 cm inferior and 2 cm medial to the anterior edge of the acromion through the rotator interval and into the joint in the anterior triangle between the biceps and the subscapularis tendons. A #11 blade is used to make a stab incision through the skin along Langer?s lines and insert an operating cannula such as a clear crystal cannula (Arthrex, Naples, FL) over a blunt trocar.

2.2.3 Midlateral Subacromial Portal (MLSP)

? This portal is created after lowering the arm into the bursoscopy position (15� of abduction; 5� of forward flexion) and following completion of the bursectomy providing visualization of the rotator cuff tear.

? A spinal needle is placed approximately 3 cm lateral to the edge of the acromion, typically anterior to the orientation line drawn when tracing the bony landmarks (? Fig. 2.1). It is important to locate the portal on the ?50-yard line,? a position directly in line with the center of the cuff tear (not the center of the acromion).

? Insert the smooth 6.25-mm clear cannula with a tapered obturator.

? A radiofrequency ablater can be placed in this portal to remove any soft tissue from the undersurface of the acromion, including the AC ligament and to define the borders of the acromion for the subacromial decompression (SAD).

? A bur or high-speed bone-cutting shaver can be the placed through the lateral portal to start the SAD. The scope is placed into the lateral portal and the bur is placed in the posterior portal to complete the SAD.

2.3 Surgical Technique

? 15-point arthroscopy of the shoulder is performed. The glenohumeral joint is viewed from the anterior and posterior portals while the subacromial position is evaluated with the arthroscope in the anterior, posterior, and lateral ports.

? In the glenohumeral position, debride the frayed edges of the cuff tendon on the articular side using a 4.0?5.5 mm shaver.

? Debride the footprint area on the articular side of the greater tuberosity from both the anterior and posterior portals.

? Lower the arm into the bursoscopy position.

? Insert the scope into the bursa via the PMGP and reposition the cannula in the AMGP to enter the subacromial space.

? Insert the shaver into the anterior portal to start the bursectomy and remove the anterior bursal curtain; then switch the scope and shaver to complete the bursectomy by shaving the remaining posterior bursa, especially the posterior bursal curtain.

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Fig. 2.1 The midlateral subacromial portal (MLSP) is identified with a spinal needle placed lateral to the acromial margin at the midpoint of the rotator cuff tear, not the midpoint of the acromion.

? Create the midlateral portal (outside-in) as described above.

? Place the radiofrequency ablater in the lateral portal to remove soft tissue from the undersurface of the acromion, followed by the bur to start the SAD. The anterolateral corner of the acromion and the lateral margin are typically burred at this point.

? Place the scope in the lateral portal and place the bur posteriorly to complete the SAD. The posterior AC joint marks the posteromedial corner of the resection. The medial acromial facet is carefully resected.

? The bone on the proximal humerus surface adjacent to the cartilage edge may require further shaving to remove any remaining soft tissue.

? The rotator cuff tissue is evaluated for quality and mobility. How well it can be brought laterally without undue tension is assessed with a grasper. The natural tension of the rotator cuff tissue is respected.

? We prefer medial row suture anchor placement to respect the tissue?s natural tension and biology. This is adjacent to the humeral head cartilage or on the medial aspect of the greater tuberosity. Placing unnatural or excessive tension on the repair via lateralization may compromise the repair.

? Gentle releases may be performed, capsular or subacromial, to help mobilize the rotator cuff tears. Aggressive slides are typically avoided to preserve the quality and integrity of the already compromised rotator cuff tissue.

? A spinal needle is utilized to identify the location of the first suture anchor placement percutaneously. Multiple anchors may be placed with one well-chosen percutaneous position as confirmed by the spinal needle (? Fig. 2.2). The first triple-loaded suture anchor is placed posteriorly with subsequent suture anchors placed anteriorly.

? Once the appropriate location is identified with the spinal needle, just off the edge of the acromion, a small skin incision is made.

? A starter punch is placed in the chosen anchor position followed by placement of a triple-loaded suture anchor with the vertical orientation lines perpendicular to the cuff.

? The most posteromedial suture is retrieved through the anterior portal using a crochet hook. The chosen suture is retrieved medial to the other sutures. A Spectrum (ConMedLinvatec, Largo, FL) suture passer, often a medium crescent, is pierced through the posterior edge of the cuff tear and a #1 polydioxanone suture (PDS) is passed through the cuff and retrieved using a grasper from the anterior portal.

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Fig. 2.2 A spinal needle is placed percutaneously near the lateral acromial border to identify the ideal location for percutaneous anchor placement; the spinal should easily access the medial greater tuberosity adjacent to the humeral head cartilage and, if well placed, can allow multiple suture anchors anteriorly and posteriorly.

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Fig. 2.3 (a,b) Final SCOI row rotator cuff repair that is biomechanically sound with triple-loaded suture anchors, medialized for a tension-free repair and biologically augmented by bone marrow vents.

? The PDS is tied around the previously retrieved suture or the Super Shuttle (ConMedLinvatec) is loaded in the anterior portal and passed back out the posterior portal.

? The partner suture limb is retrieved out of the posterior portal using the crochet hook. The suture may be tied now with the ?tie-as-you-go? technique or it may be provisionally held in Suture Savers (ConMedLinvatec) and tied at the end to make sure no dog-ears or malreduction is performed. If the ?tie-as-you-go? technique is used, careful templating of the suture anchors and suture placement in the rotator cuff must be performed prior to actual placement. The sutures are tied using an SMC sliding knot and backed up with three alternating half hitches on reversed posts.

? The remaining two sutures from the anchor are passed and tied in the same fashion using whichever curve of the Spectrum hook that makes passing the stitch easiest. Each suture should be situated equally apart with the center suture being directly in line with the center of the anchor.

? If needed, a second suture anchor is placed depending on the size of the tear. More than two anchors may be necessary if the tear is larger than 2 cm.

? A mini-Revo punch (ConMedLinvatec) is used to create bone marrow vents in the greater tuberosity lateral to the rotator cuff repair to allow the release of mesenchymal stem cells, platelets, growth factors, and cytokines to form a super clot over the footprint and repair site that will form the so-called ?crimson duvet? (? Fig. 2.3).

2.4 Surgeon Tips and Tricks

? A triple-loaded suture anchor will ensure excellent and adequate biomechanical fixation of the rotator cuff repair.1

? Medialization of the suture anchor placement will ensure minimum tension on the rotator cuff repair.2

? Bone marrow vents optimize biologic healing.3

? The combination of the above three factors helps constitute the basis of the SCOI row repair, a very specific repair technique that does not fall within the typical single-row or double-row repair techniques described and which also has documented healing rates of 91% in medium-to-large rotator cuff tears.4

? An alternative method to the ?tie-as-you-go? technique demonstrated in ? Video 2.1 involves placing small plastic straws called suture savers around each pair of consecutively passed suture limbs to temporarily reduce the cuff to the footprint. These sutures are then retrieved out of the lateral portal (viewing from the anterior portal) and tied typically in an anterior-to-posterior manner.

? Suture anchors are always inserted near the medial edge of the anatomical neck a few mm away from the humeral head cartilage instead of the lateral placement on the greater tuberosity.

? Anchors are placed at a 45� or ?tent peg? angle under the subchondral bone.

? Bone marrow vents are created throughout the tuberosity during the repair to allow healing bone marrow elements to flow out to cover and nourish the healing tendon, creating a ?crimson duvet? or ?superclot.? This creates a dense, fibrous meshwork replete with mesenchymal stem cells, platelets, growth factors, and cytokines.

? The suture knot stack can be placed at the surgeon?s discretion via control of the suture loop placement with the knot pusher or with a probe.

2.5 Pitfalls/Complications

? Proper portal placement is important to optimizing a successful surgery. The lateral portal in the subacromial space placed at the midpoint of the rotator cuff tear ensures good visualization of the rotator cuff repair.

? The medial suture limb (the limb that will pass through the rotator cuff) should be retrieved medially to the other retained sutures in the suture anchor via a crochet hook. Retrieving this suture laterally instead will cross the sutures and potentially prevent a sliding knot from being performed.

? The lateral limb of the suture should be retrieved lateral to the remaining other sutures in the suture anchor. This will also prevent sutures from crossing each other and not sliding.

? Before tying a sliding suture knot, slide both limbs of the sutures fully back and forth to make sure the soon-to-be-tied suture will slide.

? A looped or pincher grasper can also be used to untwist a set of sutures before tying by looping around the suture anchor strand.

? Hard greater tuberosity bone may require a bone tap in addition to a suture anchor awl.

2.6 Rehabilitation

? The first goal is to protect the repair during the first 4 to 8 weeks to allow the repaired tissue to heal. Immobilization using an abduction sling will help accomplish this goal by allowing tension-free healing. The sling is worn 23/24 hours a day with gentle daily passive stretching.

? After 4?8 weeks of immobilization, active range of motion (AROM) may be initiated with strengthening typically 2?4 months after surgery, depending on the size of the tear and tissue quality.

? Four phases of rehabilitation (note: larger tears may require slower progression):

? Phase I (0?8 weeks): immobilization and gentle passive range of motion.

? Phase II (4?8 weeks): active AROM (AAROM), followed by AROM.

? Phase III (8?12 weeks): progressive rotator cuff and scapular strengthening.

? Phase IV (12?16 weeks): advanced strengthening.

? Gradual return to sport is initiated after completion of phase IV.

2.7 Rationale and/or Evidence for Approach

? Arthroscopic single-row rotator cuff repairs demonstrated a failure of 17 out of 18 repairs to heal.5

? Double-row repair techniques were described to restore the native footprint and increase mechanical fixation to help improve healing rates.6

? Proponents of the double-row repair believe that a single-row repair only partially restores the native rotator cuff footprint and believe that the double-row technique provides improved tendon-to-bone contract area, mechanical properties, and increased fixation strength at time zero.

? However, multiple level I and II studies fail to demonstrate a difference in clinical outcomes and re-tear rates when comparing the two techniques.7,8

? One potential explanation for this is that the supraspinatus footprint has been shown to be significantly smaller than originally described in the cadaveric study published by Curtis et al in 2006.9 A more recent anatomic study performed by Mochizuki et al found the supraspinatus footprint to be a much smaller, triangular area with the majority of the greater tuberosity covered by the infraspinatus tendon/footprint.10

? Furthermore, tears that typically occur in a hypovascular zone of the cuff requiring debridement of the degenerative nonviable edges of the cuff result in a shorter tendon to repair back to the footprint. A shorter tendon will thus require increased tension if pulled and repaired to the original length of the lateral border of the footprint as done with a double-row repair.

? Davidson and Rivenburgh published a study demonstrating that increased tension is detrimental to the repair and that functional outcome is inversely proportional to rotator cuff repair tension.11

? All the prospective randomized controlled trials comparing double-versus single-row repairs performed lateralized single-row repairs by pulling the tendon in a relatively tensioned position on the lateral edge of the tuberosity,7,8 thereby placing similar increased tension with both techniques.

? Hersche and Gerber assessed passive tension in the supraspinatus and found a 45-N differential between the medial and lateral footprint.12

? A study was published by our group at SCOI looking at in vivo measurements comparing medial versus lateral footprint positions and demonstrated a 5.4-fold increase in tension when the tendon edge was reduced to the lateral as opposed to the medial footprint.2

? Based on the aforementioned studies, we strongly encourage a low-tension repair performed best with a single row of medial anchors as described in our ?SCOI row? technique video. Triple-loaded suture anchors are always recommended based on multiple studies published by Alan Barber, demonstrating 100% increase in fixation over double-loaded single-row anchor fixation.1

? Furthermore, a study by the Hospital for Special Surgery demonstrated that increasing the number of sutures decreases cyclic gap formation and increases load to failure.13 When the number of sutures is kept constant, single-row and double-row repair constructs are biomechanically equivalent.

? Bone marrow vents created in the greater tuberosity adjacent to the repair has been shown to be important for healing.14 Bone marrow cells have been shown to infiltrate the rotator cuff using a green fluorescent protein marker in a rat model.15 Milano published a prospective randomized trial comparing cuff repair with and without marrow vents and demonstrated better healing rates in the cuffs repaired with vents.16

References

[1] Barber FA, Herbert MA, Schroeder FA, Aziz-Jacobo J, Mays MM, Rapley JH. Biomechanical advantages of triple-loaded suture anchors compared with double-row rotator cuff repairs. Arthroscopy. 2010; 26(3): 316?323

[2] Dierckman BD, Wang DW, Bahk MS, Burns JP, Getelman MH. In vivo measurement of rotator cuff tear tension: Medial versus lateral footprint position. Am J Orthop. 2016; 45(3):E83?E90

[3] Jo CH, Shin JS, Park IW, Kim H, Lee SY. Multiple channeling improves the structural integrity of rotator cuff repair. Am J Sports Med. 2013; 41(11):2650?2657

[4] Dierckman BD, Ni JJ, Karzel RP, Getelman MH. Excellent healing rates and patient satisfaction after arthroscopic repair of medium to large rotator cuff tears with a single-row technique augmented with bone marrow vents. Knee Surg Sports TraumatolArthrosc. 2018; 26(1):136?145

[5] Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004; 86(2):219?224

[6] Lo IK, Burkhart SS. Double-row arthroscopic rotator cuff repair: Re-establishing the footprint of the rotator cuff. Arthroscopy. 2003; 19(9):1035?1042

[7] Burks RT, Crim J, Brown N, Fink B, Greis PE. A prospective randomized clinical trial comparing arthroscopic single- and double-row rotator cuff repair: Magnetic resonance imaging and early clinical evaluation. Am J Sports Med. 2009; 37(4):674?682

[8] Lapner PL, Sabri E, Rakhra K, et al. A multicenter randomized controlled trial comparing single-row with double-row fixation in arthroscopic rotator cuff repair. J Bone Joint Surg Am. 2012; 94(14):1249?1257

[9] Curtis AS, Burbank KM, Tierney JJ, Scheller AD, Curran AR. The insertional footprint of the rotator cuff: An anatomic study. Arthroscopy. 2006; 22(6):609.e1

[10] Mochizuki T, Sugaya H, Uomizu M, et al. Humeral insertion of the supraspinatus and infraspinatus. New anatomical findings regarding the footprint of the rotator cuff. J Bone Joint Surg Am. 2008; 90(5):962?969

[11] Davidson PA, Rivenburgh DW. Rotator cuff repair tension as a determinant of functional outcome. J Shoulder Elbow Surg. 2000; 9(6):502?506

[12] Hersche O, Gerber C. Passive tension in the supraspinatus musculotendinous unit after long-standing rupture of its tendon: A preliminary report. J Shoulder Elbow Surg. 1998; 7(4):393?396

[13] Jost PW, Khair MM, Chen DX, Wright TM, Kelly AM, Rodeo SA. Suture number determines strength of rotator cuff repair. J Bone Joint Surg Am. 2012; 94(14):e100

[14] Snyder S, Burns J. Rotator cuff healing and the bone marrow ?crimson duvet.? From clinical observations to science. Tech Shoulder Elbow Surg. 2009; 10:130?137

[15] Kida Y, Morihara T, Matsuda K, et al. Bone marrow-derived cells from the footprint infiltrate into the repaired rotator cuff. J Shoulder Elbow Surg. 2013; 22(2):197?205

[16] Milano G, Saccomanno MF, Careri S, Taccardo G, DeVitis R, Fabbriciani C. Efficacy of marrow-stimulating technique in arthroscopic rotator cuff repair: A prospective randomized study. Arthroscopy. 2013; 29(5): 802?810