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1. Fixation techniques
in rotator cuff repair
Manos Antonogiannakis
Director
Center for shoulder arthroscopy
IASO General Hospital
Athens, Greece

2. Rotator Cuff Function
1. Dynamic stabilizer of the shoulder
2. Contributes strength to the arm
(50% of the abduction strength is generated by
supraspinatus)
3. Couple forces stabilize and regulate the
motion of the shoulder
www.shoulder.gr

3. Rotator Cuff disease
Rotator cuff disease is a wide spectrum
of clinical conditions, which range
from asymptomatic partial
thickness tears to symptomatic rotator cuff
arthropathy
www.shoulder.gr

4. Tears’ Definitions
• Partial Thickness Tears =
absence of communication between the
glenohumeral joint and the subacromial
bursa.
• Full Thickness Tears =
communication between the glenohumeral
joint and the subacromial bursa.
• Massive Tear =
Involving 2 or 3 tendons [Gerber]
or bigger than 5cm [Cofield]
www.shoulder.gr

5. Partial Thickness Tear
• Bursal side tears
• Articular side tears
• Intratendinus tears
Partial tear classification by Ellman
• Grade I <3mm deep
• Grade II 3-6mm deep
• Grade III >6mm deep (i.e. >50% thickness)
www.shoulder.gr

6. How frequent are RC Tears?
• Rotator Cuff Frequency:
30% of population
• Significant correlation with
age [Sher JS, Arthroscopy 1995]
www.shoulder.gr

7. Natural History of a Tear
• Tears DO NOT HEAL. Some but NOT ALL of them will
progress
• Rot cuff arthropathy is the end stage (4-20%)
• 50% of newly symptomatic tears will progress in size
• 20% of asymptomatic tears will progress.
• No Tear seem to decrease in size.
• 80% of partial tears progress in size or become full
thickness at 2 years
[Yamaguchi K., 2006, Nice Shoulder Course]
www.shoulder.gr

8. Partial Tears Treatment
• By far the most common partial tears are
Articular-side, vascular or age relateted
Traditionally partial tears classifications
are based to 50%
BUT
“How healthy is the remaining,
intact tissue?”
www.shoulder.gr

9. Partial Tears Treatment Options
1. Debride partial tear only
2. In-situ Repair
3. Convert to full thickness, Debride, Repair
Etiology makes the decision!!!
• Because most tears are degenerative, option 3
should be the best for most cases
• Trauma or young athletes are candidates for in-situ
repair
• If minimal partial tears cause significant pain then
debridement alone
[Yamaguch K, 2006 Nice Shoulder Course]
www.shoulder.gr

10. RC Tear Classification
Acute, Chronic, Acute on chronic
Tear Age Tissue Quality
1. Partial <40 Good
2. Complete <40 Good
3. Complete 40-65 Good
4. Complete 40-65 Bad
5. Complete >65 Good
6. Complete >65 Bad
www.shoulder.gr

11. Full thickness Tear
www.shoulder.gr

12. What is Bad Tissue Quality?
• Large or massive tears,
• Retracted tears,
• Coutallier three or four fatty infiltration
www.shoulder.gr

13. Busral view after acromioplasty
www.shoulder.gr

14. Checking Tissue Quality
www.shoulder.gr

15. Today’s Knowledge
• Rot cuff has some degree of reserve that affords
functional use of the arm in cases of limited tendon
deficiency.
• Location rather that size of a tear maybe more important
in the development of symptoms.
• Type of activities plays an important factor in the
development of symptoms
www.shoulder.gr

16. Goutallier fatty degeneration of muscles
• Stage 0 Normal muscle – no fatty streaming
• Stage 1 Occasional fatty streaming
• Stage 2 Fat<50% of cross sectioned area
Fat < Muscle
• Stage 3 Fat=50% of cross sectioned area
Fat = Muscle
• Stage 4 Fat>50% of cross sectioned area
Fat > Muscle
www.shoulder.gr

17. What to do???
• Patients with grade 3 or 4 fatty degeneration
DO NOT improve with rot cuff repair
[Goutallier]
Vs.
• Patients with grade 3 or 4 fatty degeneration
improved significant at 86% of cases after
arthroscopic repair
[Burkhart]
www.shoulder.gr

18. How to convert a Symptomatic tear to an
Asymptomatic re-tear
• Subacromial decompression and
debridmeut
• Biseps tenotomy
• Partial repair and healing of the rot cuff
• Adequate post-op rehabilitation
www.shoulder.gr

19. Early failure
of arthroscopic rot cuff repair
1. Failure of tendon-suture interface
2. Suture-anchor failure
3. Suture failure
www.shoulder.gr

20. RC Repair Results
• The rate of structural failure after open repair varies
from 20% to more 50%, while it is greater for
arthroscopic repairs
• First report of DOUBLE ROW repair:
Fealy S, Kingham TP, Altchek DW, Arthoscopy July 2002
Mini-open Rot cuff repair using a two row fixation technique
www.shoulder.gr

21. Conclusions
• Rot Cuf is extremely significant for the normal function of
the shoulder
• Rot Cuf tears can be asymptomatic
• Symptoms Produced by a tear depend on:
– Size
– Location
– Functional demands of the patient
www.shoulder.gr

22. Conclusions
• An anatomically deficient but biomechanical intact cuff is
possible
• Biomechanical intact cuff is the cuff that restores the
equilibrium of the force couples
• A cuff tear does not heal conservative
• A cuff tear after operative repair may yet not heal
• Partial healing may restore sufficient power to the cuff to
equilibrate the force couples
www.shoulder.gr

23. Conclusions
• Non-operative treatment strives to optimize the function
of the remaining cuff
• Rehabilitation after surgery strives to optimize the
function of the partially or completely healed cuff
www.shoulder.gr

24. ..so when we treat a RC tear…
We must try to:
• Optimize the anatomic integrity of the cuff by a repair
with minimal morbidity to the healthy tissues (mainly
deltoid)
THEN
• Rehabilitate vigorously the patient, to optimize the total
function of the shoulder
THEN
We can expect a majority of
satisfied patients
www.shoulder.gr

25. Our Results
• 41 pts single row repair
• Small 3 (7.31%)
• Medium 26 (63.41%)
• Large 5 (12.18%)
• Massive 7 (17.7%)
• Mean age 58.8 years
• Mean FU 14 months
• UCLA score
Excellent 10 (24.39%)
Good 20 (48.78%)
Fair 9 (21.95%)
Poor 2 (4.87%)
92% Substantial Improvement
in Pain
[Acta Orthopedica Hellenica, 2007]
www.shoulder.gr

26. www.shoulder.gr
Case Presentation

27. www.shoulder.gr
Case Presentation

28. FIRST: Have Good Friends around !

29. Light General Anesthesia
with Laryngeal Mask

30. Plus Local Anesthesia
Scalene Block

31. Positioning the patient
Lateral decubitus
My preferred position

32. Patient Positioning
Padding bony prominences
Beware of the neck

33. Room Set up
Lateral decubitus allows easy access to the
anterior and posterior part of the joint

34. Keep the operating room cold
to avoid fogging
but
Keep the
patient warm

35. Beach Chair position
Equally suitable but ask those who use it
for tips and secrets tomorrow !!!

36. Basic Arthroscopic Tools
Have them all ready from the beginning

37. Draping

38. Traction:
NOT more than 4 Kgrs

39. Instruments in side pocket –
easily available

40. Is everything ready BEFORE starting ?

41. The arthroscopic tower opposite the
surgeon

42. Commonly used tools arranged by the
scrub nurse

43. Skin Marking

44. Before Entering with the Scope
Saline Backflow
Saline in

45. Starting with the scope portal

46. 30º Scope inserted into the joint

47. Anterior Superior Portal

48. Working Team

49. Thank you

50. Massive Rot Cuff TearsMassive Rot Cuff Tears
Definition:Definition:
• Involving 2 or more Tendon TearsInvolving 2 or more Tendon Tears (Gerber)(Gerber)
• >5cm Tear>5cm Tear (Cofield)(Cofield)

51. The problemThe problem
• Poor tendon qualityPoor tendon quality
• Muscle tendon retractionMuscle tendon retraction
• Muscular atrophy fatty infiltrationMuscular atrophy fatty infiltration
The three central issuesThe three central issues
• Passive range of motionPassive range of motion
• Tendon retractionTendon retraction
• Muscle viabilityMuscle viability
• Failure of healingFailure of healing

52. Techniques of releasesTechniques of releases
• The techniques adapted from openThe techniques adapted from open
surgery as described by Codmann,surgery as described by Codmann,
Rockwood, NeerRockwood, Neer
• Refined and modernized by Esch, Snyder,Refined and modernized by Esch, Snyder,
Gartsman, Burkhart and othersGartsman, Burkhart and others

53. ANY TYPE OF RECONSTRUCTIONANY TYPE OF RECONSTRUCTION
MUST AVOID TENSION OVER-LOADMUST AVOID TENSION OVER-LOAD
OF THE REPAIROF THE REPAIR

54. The solutionThe solution
• Improve the mechanical strength of theImprove the mechanical strength of the
repairrepair
• Enhance the biological responseEnhance the biological response
• Abandon and replace-muscle transferAbandon and replace-muscle transfer
• Rot cuff arthropathy-reverse or extendedRot cuff arthropathy-reverse or extended
head arthroplastyhead arthroplasty

55. Recognize the Tear PatternRecognize the Tear Pattern
• Tears must be repaired in theTears must be repaired in the
direction of greatest mobility ->direction of greatest mobility ->
minimal strainminimal strain

56. Mobility Check

57. Tendon debridement- Tear morphology
recognition

58. Tear PatternsTear Patterns
• Crescent shapedCrescent shaped
• L-shaped (or reverse L)L-shaped (or reverse L)
• U-ShapedU-Shaped
• Massive Contracted Immobile tearsMassive Contracted Immobile tears
S.S. BurkhartS.S. Burkhart

59. Crescent
Shaped Tear
S.S Burkhart

60. Crescent-Shaped TearCrescent-Shaped Tear
• Double row repair,Double row repair,

61. Double Row Fixation
Restoration of the footprint
www.shoulder.gr

62. Tuberoplasty

63. 1st
Anchor Insertion – Medial Row

64. 1st
suture passage- Medial row - mattress

65. suture passage- Medial row – post. anchor

66. Suture inspection – medial row - mattress

67. Lateral Row 1st
Anchor Insertion

68. Lateral Row 2nd
Anchor Insertion

69. Inspection of Suture Position

70. Knot Tying Lateral Row

71. Final Repair
Double rowDouble row
Probably stronger repair
but
Time consuming and of
raised difficulty

72. L-Shaped & U-Shaped TearsL-Shaped & U-Shaped Tears
Greater mobility from anterior toGreater mobility from anterior to
posterior than medial to lateralposterior than medial to lateral

73. L-Shaped & U-Shaped TearsL-Shaped & U-Shaped Tears
• Side to side sutures from medial to lateralSide to side sutures from medial to lateral
• Progressively converge the margin of theProgressively converge the margin of the
tear lateral to bone bedtear lateral to bone bed
• Closing 50% of a U-Shaped tear ->Closing 50% of a U-Shaped tear ->
reduces strain at converge margin by areduces strain at converge margin by a
factor of 6factor of 6
[[S. S .Burkhart]S. S .Burkhart]

74. Closing an L-shaped or U-shaped tear is much like closing a tent flap
Closure of an U-shaped tear involves first side-to-side closure
of the vertical limb of the tear, then tendon-to-bone closure of the
transverse limb
L or U -shaped tear
S. S .BurkhartS. S .Burkhart

75.  Large U-shaped cuff tear
extending to glenoid
 Margin convergence
 The free margin of the cuff is
repaired to bone with suture
anchors

76. Side to Side Repair
Cuff repair
www.shoulder.gr

77. Side to Side Repair

78. Cuff repairCuff repair
Tendon to bone repairTendon to bone repair
www.shoulder.gr

79. Massive Contracted Immobile TearsMassive Contracted Immobile Tears
• No mobility from medial to lateral or fromNo mobility from medial to lateral or from
anterior to posterioranterior to posterior
• Subcategories:Subcategories:
– Massive Contracted Longitudinal TearsMassive Contracted Longitudinal Tears
– Massive Contracted Crescent TearsMassive Contracted Crescent Tears
• Represent 9.6% of massive tearsRepresent 9.6% of massive tears
[[S.Burkhart]S.Burkhart]

80. Massive Contractite TearsMassive Contractite Tears
• Anterior Interval SlideAnterior Interval Slide
and/orand/or
• Posterior Interval SlidePosterior Interval Slide
Single and double interval slideSingle and double interval slide

81. Subacromial viewSubacromial view

82. Single and double interval slideSingle and double interval slide
• Anterior slide through release in theAnterior slide through release in the
rotator interval (supraspinatus–rotator interval (supraspinatus–
coracobrachialis)coracobrachialis)
• Posterior slide through release of thePosterior slide through release of the
interval supraspinatus-infraspinatusinterval supraspinatus-infraspinatus

83. Free sutures to the cuffFree sutures to the cuff

84. Anterior slide-
supraspinatus
from coracoid –
coracohumeral
ligament

85. Posterior slide
Infraspinatus-supraspinatus

86. Posterior slide

87. Side to side sutures

88. Final Subacromial viewFinal Subacromial view

89. Massive TearsMassive Tears
associated withassociated with
Subscapularis TearsSubscapularis Tears
• Subscapularis must be mobilized andSubscapularis must be mobilized and
repaired prior to the rest of the cuffrepaired prior to the rest of the cuff
• Interval slide in continuityInterval slide in continuity

90. Subscapularis
Repair
Recognition

91. Subscapularis
Repair
Recognition

92. Subscapularis RepairSubscapularis Repair

93. Bicepts tenodesisBicepts tenodesis

94. Massive TearsMassive Tears
May beMay be
• Eassily repairableEassily repairable
• Retracted very difficult to repair (anterior &Retracted very difficult to repair (anterior &
posterior Slides)posterior Slides)
• Medially RepairedMedially Repaired
• Impossible to repairImpossible to repair
• Incomplete RepairIncomplete Repair
• Graft JacketsGraft Jackets
• Tendon trasfersTendon trasfers
• Reverse, extended head arthroplastyReverse, extended head arthroplasty

95. Arthroscopic cuff repairArthroscopic cuff repair
Wolf, Snyder, Gartsman, Esch,
Burkhart, Tauro and others reported
84%-94% excellent and good results

96. Results for massive tearsResults for massive tears
• 95% Good to Excellent Results95% Good to Excellent Results
independent to tear sizeindependent to tear size [Burkhart, 2001][Burkhart, 2001]
• With interval slideWith interval slide
• Improve UCLA score (10->28.3)Improve UCLA score (10->28.3)
• Improve Active ROM, StrengthImprove Active ROM, Strength
[Burkhart, 2004][Burkhart, 2004]
• Graft Jacket RepairGraft Jacket Repair
• Improve UCLA score (18->32Improve UCLA score (18->32))
[Snyder, 2008][Snyder, 2008]

97. ConclusionsConclusions
• Acute Crescent TearAcute Crescent Tear
Standard Techniques for tendon to bone fisxationStandard Techniques for tendon to bone fisxation
• U- or L- shaped TearsU- or L- shaped Tears
• Side to side margin convergenceSide to side margin convergence
• Partial mobile tearsPartial mobile tears
• Anterior / Posterior SlideAnterior / Posterior Slide
• Medialized RepairMedialized Repair
• Irreparable TearsIrreparable Tears
• Partial RepairPartial Repair
• GraftsGrafts
• Tendon trasfersTendon trasfers

98. What to do???What to do???
• Patients with grade 3 or 4 fatty degenerationPatients with grade 3 or 4 fatty degeneration
DO NOTDO NOT improve with rot cuff repairimprove with rot cuff repair
[Goutallier][Goutallier]
Vs.Vs.
• Patients with grade 3 or 4 fatty degenerationPatients with grade 3 or 4 fatty degeneration
improved significant at 86% of cases afterimproved significant at 86% of cases after
arthroscopic repairarthroscopic repair
[Burkhart][Burkhart]

99. In our experienceIn our experience
Patients withPatients with massivemassive rot cuff tearsrot cuff tears
benefitbenefit from surgeryfrom surgery
but they tend to recover slowlybut they tend to recover slowly
they succeed very good pain reliefthey succeed very good pain relief
but strength deficits remainbut strength deficits remain

100. In our experienceIn our experience
• Patients with upward migration of thePatients with upward migration of the
femoral head in contact with the acromionfemoral head in contact with the acromion
do not benefit from arthroscopydo not benefit from arthroscopy
• Patients with painless external rotation lagPatients with painless external rotation lag
and inability to keep the arm in externaland inability to keep the arm in external
rotation do not benefit from arthoscopyrotation do not benefit from arthoscopy
• With raised experience more previousWith raised experience more previous
irreparable cuff tears can be repairedirreparable cuff tears can be repaired

102. Surgical Technique
1. GH Joint and Subacromial Joint Inspection
2. Bursal debridement
3. Acromioplasty
4. Cuff mobilization
5. Repair (side to side, tendon to bone)

103. Portals
Outside in technique

104. Bleeding control

105. Bleeding control

106. Joint Side Inspection

107. Bursal Side Inspection-Bursectomy

108. Tendon debridement- Tear morphology recognition

109. Acromioplasty

110. Double Row Fixation
Restoration of the footprint

111. Lateral Row Suture Passage

112. Inspection from the
Glenohumeral Joint

113. Mobilization of the Articular
Part of the Rotator Cuff

114. 2nd
suture passage- Medial row - mattress

115. Knot Tying Lateral Row

116. Knot Tying Lateral Row

117. Knot Tying Mattress Medial Row

118. Knot Tying Mattress Medial Row

119. 4rd suture passage- Medial row - mattress

120. suture passage- Medial row – post. anchor

121. Lateral Row Suture Passage

122. Final Inspection