Arthroscopic Rotator Cuff Repair

Transcription

1 Arthroscopic Rotator Cuff Repair CHRISTOPHER S. AHMAD, MD; WILLIAM N. LEVINE, MD; LOUIS U. BIGLIANI, MD Arthroscopic rotator cuff repair offers less pain, quicker recovery, and less stiffness compared with mini-open repair techniques. Ideal management of partial thickness and massive rotator cuff tears continues to challenge the orthopedic surgeon. With recent advances in technique, surgical options have evolved from simple open debridement to complete all arthroscopic repair for even the largest rotator cuff tears. 1-3 Increased capability of all arthroscopic rotator cuff repair techniques has been attributed to improved recognition of rotator cuff tear patterns, tendon mobilization, suture passing instrumentation, and suture anchor implants. Several recent reports with short-term followup for arthroscopic rotator cuff From the Center for Shoulder, Elbow, and Sports Medicine, Department of Orthopedic Surgery, Columbia University, New York, NY. Reprint requests: Christopher S. Ahmad, MD, Dept of Orthopedic Surgery, 622 W 168th St, PH11-14, New York, NY repair have shown encouraging results 4-7 and compare well to traditional open rotator cuff repair. 8,9 Arthroscopic techniques appear to offer less pain, quicker recovery, and less stiffness than open or mini-open repair techniques. Thus, the arthroscopic repair technique is becoming more popular among arthroscopists and shoulder surgeons. The techniques continue to evolve with current emphasis on anatomically restoring the torn tendon edge to its native insertion footprint with optimal fixation. 10 SURGICAL GOALS The basic principles of open rotator cuff repair are applied to arthroscopic rotator cuff repair: 1) preservation or meticulous repair of the deltoid origin, 2) adequate decompression of the subacromial space, 3) tension free repair, 4) secure fixation of the tendon to the greater tuberosity, and 5) supervised rehabilitation. The role of arthroscopy in rotator cuff repair varies, from minimal use for diagnostic purposes alone or to facilitate complete rotator cuff repair. A common arthroscopic-assisted technique is to perform diagnostic arthroscopy and arthroscopic subacromial decompression followed by a mini-open rotator cuff repair. ADVANTAGES OF ARTHROSCOPIC-ASSISTED Arthroscopic treatment offers the advantage over traditional open repair of more thorough diagnostic evaluation and treatment of lesions within the glenohumeral joint. Miller and Savoie 11 reported a 76% prevalence of intra-articular pathology in patients undergoing mini-open rotator cuff repair, emphasizing the advantage of glenohumeral arthroscopy. Gartsman et al 5 further demonstrated that the treatment of intra-articular lesions can affect outcome. Traditional open surgical management of rotator cuff disease usually is limited by the anterolateral exposure in which the cuff must be manipulated to the window of the approach. Arthroscopy facilitates more thorough assessment and treatment of rotator cuff tears by approaching the shoulder from multiple different angles. Another arthroscopic advantage is preservation of the deltoid attachment to the acromion with arthroscopic acromioplasty. Deltoid detachment that fails to heal following open rotator cuff repair remains a devastating complication. In addition, the postoperative rehabilitation is potentially accelerated if the deltoid does not require protection. A third advantage is supported by recent data 12,13 that indicates complete arthroscopic repair achieves better early range of motion and decreased postoperative pain. A final advantage is in the ability of arthroscopy to facilitate precise soft-tissue releases that mobilize the torn rotator cuff for a tension free repair. DISADVANTAGES OF COMPLETE ARTHROSCOPIC Rotator cuff fixation with 570 ORTHOPEDICS

2 Cover Story 2004 Teri J. McDermott CMI transosseous tunnels has traditionally been used for open rotator cuff repair with the goal to optimize fixation strength and reproduce the anatomic footprint of tendon attachment. Arthroscopic repair techniques in general require use of suture anchors and limit some suture configuration options in the tendon. Several cadaver studies with cyclic loading suggest suture anchors provide superior fixation than traditional transosseous techniques. 14,15 The strength of initial fixation, however, may not be as important as the biologic capacity for healing. Another disadvantage of arthroscopic rotator cuff JUNE 2004 Volume 27 Number 6 571

3 1A 1B 1C 1D 1E Figure 1: Lateral arthroscopic views of a crescent shaped tear (A), following anatomic repair to the tuberosity (B), a massive U-shaped tear (C) following margin convergence of the massive U-shaped tear (D), and following anatomic repair to the tuberosity (E). repair is the technical difficulty, which requires adequate experience. Lastly, arthroscopic repair requires significantly greater and more complex instrumentation and potentially longer operative time. Arthroscopic rotator cuff repair has also been criticized because suture anchors may not restore the normal footprint of the rotator cuff. Recently, double row suture fixation techniques have been used to maximize the repair Arthroscopy facilitates more thorough assessment and treatment of rotator cuff tears by approaching the shoulder from multiple different angles. of the normal footprint. 10 Still, concerns exist regarding the effect of having twice as many anchors in the greater tuberosity. ARTHROSCOPIC TECHNIQUE The steps in arthroscopic rotator cuff repair are as follows: diagnostic arthroscopy and tear pattern identification, tendon releases and mobilization, tuberosity preparation, margin convergence as necessary, and tendon repair to the tuberosity. Diagnostic arthroscopy of the glenohumeral joint assesses the biceps, labral, and chondral pathology. The entire rotator cuff is inspected with internal and external rotation of the humerus to delineate the tear characteristics. The tear may be further defined during the bursal arthroscopy. Four major types of rotator cuff tear patterns have been described 1,2 and are based on the shape and mobility of the tear margins crescent-shaped, U-shaped, L- shaped, and massive, contracted, immobile tears. Retracted tears require release to facilitate mobilization for tension-free repairs. Adhesions of the articular side of the rotator cuff to the glenoid are released with electrocautery, arthroscopic basket forceps, or arthroscopic elevators. A thorough bursectomy is 572 ORTHOPEDICS

4 performed with a motorized shaver from the subacromial space. Rotator cuff adhesions to the acromion and scapular spine are released. When substantial retraction of the anterior aspect of the supraspinatus is present, a rotator interval release or an interval slide can be performed, which includes division of the coracohumeral ligament. The tear pattern is then confirmed. The mobility of the anterior and posterior leaves of the tear are assessed from medial to lateral and posterior to anterior for each aspect of the tear using a soft-tissue grasper. Healing potential of the repair is improved with debridement of the tear edge with arthroscopic basket forceps and a motorized shaver. The greater tuberosity is prepared by removing soft tissue and abrading the bone using a shaver but a formal trough is not necessary. Tears that demonstrate mobility in the anterior to posterior directions benefit from tension decreasing margin convergence techniques. This technique decreases the tear size and makes subsequent mobilization of the remaining edge to the greater tuberosity easier. Although margin convergence is appropriate for many tears with a substantial side-toside or intrasubstance extension, it should not be substituted for traditional releases to obtain a reduction of the rotator cuff to the greater tuberosity. The technique of margin convergence not only allows repair of seemingly irreparable tears but also minimizes strain at the repair site. 16 This decreases the failure risk of the rotator cuff repair. Burkhart et al 4 outlined the approach to the different tear patterns. Crescent-shaped tears are the simplest tears and demonstrate minimal retraction and excellent mobility (Figure 1A). They are repaired directly to bone with minimal tension (Figure 1B). Anchors are placed percutaneously by using a spinal needle to identify location and direction. Typically, a hole is created with a drill or punch and the implant placed. The sutures are managed through the percutaneous insertion site and accessory cannulae. Suture passing techniques are then used with one of numerous available devices to shuttle one limb of the anchor suture into the inferior surface of the rotator cuff to exit the tendon along its superficial surface. After all sutures are passed through the tendon, arthroscopic knot-tying is performed. The limb of the suture exiting the tendon is used as the post. The surgeon must be familiar with various knot-tying techniques, including sliding and non-sliding knots. The process is repeated sequentially with another suture anchor as needed. Passing each suture anchor separately after the preceding suture anchor has been tied and cut minimizes problems with suture management; it substantially decreases the complexity of the procedure and avoids suture tangling. U-shaped rotator cuff tears extend much farther medially than crescent-shaped tears, with the apex of the tear adjacent to or medial to the glenoid rim (Figure 1C). The apex of the tear does not mobilize medially despite releases and creates excessive tensile stresses in the middle of the repaired rotator cuff margin. These tear patterns demonstrate significant mobility from an anterior-to-posterior direction and should be initially repaired using margin convergence. Following the margin convergence (Figure 1D), the free margin of the rotator cuff can be easily repaired to the bone bed in a tension-free manner (Figure 1E). The L-shaped tears are similar to U-shaped tears. However, one of the leaves (usually the posterior leaf) is more mobile than the other leaf and can be easily brought to the bone bed and to the other leaf. In these cases, side-to-side suturing is first performed along the longitudinal split and then the converged margin is repaired to bone. The more mobile leaf must be advanced both laterally to the greater tuberosity and toward the less mobile leaf. TRANSITION TO ARTHROSCOPIC ROTATOR CUFF Although arthroscopic rotator cuff repair offers many advantages, it remains technically demanding. Success in transitioning from a traditional mini-open repair technique to a complete arthroscopic cuff repair is best accomplished by successively performing more of the procedure arthroscopically as the surgeon gains confidence and experience. The strategy can start with an arthroscopic decompression of the subacromial space and A common arthroscopic-assisted technique is to perform diagnostic arthroscopy and arthroscopic subacromial decompression followed by a mini-open rotator cuff repair. arthroscopic deep surface releases of the rotator cuff. First, circumferential lysis of adhesions from the undersurface of the rotator cuff to the superior aspect of the glenoid labrum is completed. This is a relatively easy skill to obtain, as most surgeons are comfortable with performing glenohumeral arthroscopy. After the deep surface releases and an extensive subacromial bursectomy have been performed, much of the rotator cuff should be freely mobile for repair. The final release, which can be difficult, involves mechanical or sharp debridement around the coracoid base, including the coracohumeral ligament. Once a surgeon is able to perform the arthroscopic releases and decompression of the rotator cuff in a timely fashion, the next step is to place sutures in the cuff. A variety of commercially available suture passing devices are available. Initially, the surgeon may place a few sutures, JUNE 2004 Volume 27 Number 6 573

5 which can be used for control. The surgeon may convert to a mini-open during this phase as comfort level dictates. RESULTS OF ARTHROSCOPIC Multiple short-term studies have demonstrated a substantial improvement in function, decrease in pain, and improvement in satisfaction for patients who have undergone arthroscopic rotator cuff repair. The level of success has been similar to that achieved with the mini-open technique. 4,5,7 Early reports for arthroscopic repairs were reserved for small, nonretracted tears whereas open techniques were used for large or massive tears. Despite such limitations, these studies have documented positive outcomes in several different patient populations. Subsequent studies have shown that massive tears can be repaired arthroscopically without compromising the results. 1,7 In those studies, comparison of patient populations with small ( 1 cm), medium (1-3 cm), and large ( 3 cm) tears revealed no differences in outcome scores. Also, no difference in outcome was noted among patients of different ages, suggesting that the arthroscopic repair is equally effective in all age groups. 17 Two studies have directly compared mini-open and arthroscopic techniques by the same surgeon and in the same patient population and have Arthroscopic techniques appear to offer less pain, quicker recovery, and less stiffness than open or mini-open repair techniques. shown similar results. 12,13 In the study by Weber, 12 95% of the arthroscopic repairs were done on an outpatient basis, compared to only 28% of the miniopen repairs. Although the two studies have contributed to our confidence in performing these repairs, the ideal study, which would include random selection and prospective and blind evaluation of patients, has not yet been done. Most of the early studies on arthroscopic rotator cuff repair have focused on clinical outcome. Little has been done to evaluate the integrity of the cuff with either imaging or arthroscopic techniques. Although a fairly high prevalence of incomplete healing has been reported after mini-open repairs, patients still had a good clinical outcome; however, patients in whom the repaired rotator cuff remained intact had better strength. 8,18,19 Ball et al 20 performed ultrasound for 20 consecutive patients who underwent an arthroscopic repair of a massive, chronic tear and, despite excellent clinical results, found disruption in 90%. Since open rotator cuff remains the gold standard, further research is required to directly compare arthroscopic and open techniques. REFERENCES 1. Burkhart SS. Arthroscopic treatment of massive rotator cuff tears. Clin Orthop. 2001; 390: Burkhart SS. A stepwise approach to arthroscopic rotator cuff repair based on biomechanical principles. Arthroscopy. 2000; 16: Gartsman GM. Massive, irreparable tears of the rotator cuff. Results of operative debridement and subacromial decompression. J Bone Joint Surg Am. 1997; 79: Burkhart SS, Danaceau SM, Pearce CE Jr. Arthroscopic rotator cuff repair: analysis of results by tear size and by repair technique-margin convergence versus direct tendon-to-bone repair. Arthroscopy. 2001; 17: Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator cuff. J Bone Joint Surg Am. 1998; 80: Murray TF Jr, Lajtai G, Mileski RM, Snyder SJ. Arthroscopic repair of medium to large fullthickness rotator cuff tears: outcome at 2- to 6-year follow-up. J Shoulder Elbow Surg. 2002; 11: Tauro JC. Arthroscopic rotator cuff repair: analysis of technique and results at 2- and 3-year follow-up. Arthroscopy. 1998; 14: Harryman DT II, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen FA III. Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff. J Bone Joint Surg Am. 1991; 73: Bigiliani LU, Kimmel J, McCann PD, Wolfe I. Repair of rotator cuff tears in tennis players. Am J Sports Med. 1992; 20: Apreleva M, Ozbaydar M, Fitzgibbons PG, Warner JJ. Rotator cuff tears: the effect of the reconstruction method on three-dimensional repair site area. Arthroscopy. 2002; 18: Miller C, Savoie FH. Glenohumeral abnormalities associated with full-thickness tears of the rotator cuff. Orthop Rev. 1994; 23: Weber S. Comparison of all arthroscopic and mini-open rotator cuff repairs. Presented at: the Annual Meeting of the Arthroscopic Association of North America; April 19-22, 2001; Seattle, Wash. 13. Nottage W, Severud E. A comparison of all arthroscopic vs. mini-open rotator cuff repair: results rat 45 months. Presented at: the Summer Institute Meeting of the American Academy of Orthopaedic Surgeons; September 6-9, 2001; San Diego, Calif. 14. Reed SC, Glossop N, Ogilvie- Harris DJ. Full-thickness rotator cuff tears. A biomechanical comparison of suture versus bone anchor techniques. Am J Sports Med. 1996; 24: Hecker AT, Shea M, Hayhurst JO, Myers ER, Meeks LW, Hayes WC. Pull-out strength of suture anchors for rotator cuff and Bankart lesion repairs. Am J Sports Med. 1993; 21: Burkhart SS, Athanasiou KA, Wirth MA. Margin convergence: a method of reducing strain in massive rotator cuff tears. Arthroscopy. 1996; 12: Stollsteimer GT, Savoie FH III. Arthroscopic rotator cuff repair: current indications, limitations, techniques, and results. Instr Course Lect. 1998; 47: Bigliani LU, Cordasco FA, McIlveen SJ, Musso ES. Operative treatment of failed repairs of the rotator cuff. J Bone Joint Surg Am. 1992; 74: Kirschenbaum D, Coyle MP Jr, Leddy JP, Katsaros P, Tan F Jr, Cody RP. Shoulder strength with rotator cuff tears. Pre- and postoperative analysis. Clin Orthop. 1993; 288: Ball CM, Galatz LM, Teefey SA, Middleton WD, Yamaguchi K. Complete arthroscopic repair of large and massive rotator cuff tears. Correlation of functional outcome with repair integrity. Presented at: the Annual Meeting of the American Academy of Orthopaedic Surgeons; February 13-17, 2002; Dallas, Tex. Section Editor: Bennie G.P. Lindeque, MD 574 ORTHOPEDICS