Introduction

Arthroscopic surgery involves the use of a special camera attached to a long, narrow surgical telescope to visualize the inside of a joint. Working through small incisions about the size of dress shirt buttonholes, the surgeon can use specially created instruments to repair damaged cartilage, capsule, tendon, and other tissues. The camera transmits the signal to a video monitor for improved visualization, as well as allowing photographic and videographic documentation of the surgical findings and the procedure performed. In orthopaedic surgery, arthroscopy was first used to treat conditions of the knee. With new technology and refined techniques, arthroscopic surgery has become quite common in treating many knee, shoulder, elbow, wrist, hip, ankle, and foot problems. 

Arthroscopic treatment of rotator cuff disease initially consisted of rotator cuff inspection and debridement and arthroscopic acromioplasty. If a repairable rotator cuff tear was discovered, an open or “mini-open” repair of the tendon was then performed. As surgeons’ skills improved, and with more specialized instrumentation, it became possible to fix relatively small tears using arthroscopic techniques to insert anchors, pass sutures, and ties knots. It is now not uncommon for surgeons who perform shoulder arthroscopy routinely to repair even large rotator cuff tears using these techniques.

Preoperative Preparation 

At the Orthopaedic Surgery Center of Orthopaedic Associates of Portland, patients are seen prior to the day of surgery for a preoperative orientation visit. A complete History and Physical Examination is performed to ensure appropriate attention to all medical conditions prior to surgery. The anesthesiologists from Maine Medical Center who staff the center are also available for preoperative consultation. Preoperative teaching is an important part of this visit as well. As a result, patients generally feel well prepared for their surgical procedure.

Arthroscopic rotator cuff repair is a technically challenging procedure that requires advanced arthroscopic surgical skills, careful preoperative planning, and a step-wise, systematic approach. The procedure may be performed with the patient in a “beach chair” (sitting) or a lateral decubitus (side-lying) position and is usually done under general anesthesia. Small (5mm) incisions are created in the back, side, and front of the shoulder, and the arthroscope and instruments may be switched between each of these positions as necessary. A complete diagnostic arthroscopy and bursoscopy (inspection of bursa) is initially performed. Care is taken to inspect the biceps tendon within the shoulder, the fibrous ring or “labrum” which surrounds the glenoid, the capsule and ligaments, the cartilage surfaces of the head and glenoid, and the rotator cuff tendons. Any pathology is addressed only after a complete inspection, so as not to miss any significant findings. 

Figure 1. Visualizing torn rotator cuff from within the joint. The biceps tendon is running vertically on the left.

Figure 2. View of large tear from posterior (behind). Socket is to the right.

Careful preoperative x-ray evaluation of the shape and size of the acromion, and notation of any spurs, serves as a guide for the extent of any acromioplasty (undersurface smoothing) necessary. Because the arthroscope magnifies the structures seen, irregularities in the surface of less that 1 mm may be seen and removed. The goal is to smooth and flatten the under-surface of the acromion to provide more room for the repair and to relieve pressure from the healing tendon. An overly aggressive acromioplasty must be avoided, as excessive removal of the anterior acromion can result in the humeral head sliding forward and up out of the socket (anterosuperior subluxation).

The rotator cuff tear is then visualized through the lateral (side) portal from the “50 yard line view.” The size and pattern of the tear is assessed. Any thin or fragmented portions are removed and the area where the tendon will be reattached to the bone is lightly debrided to encourage new blood vessel ingrowth for healing.

Figure 5. View of large tear from the “50 yard line.”	Figure 6.Preparing the humerus for tendon reattachment.
Figure 7. Larger V or U shaped tears may require side to side stitches to begin to close the defect.	Figure 8. The side to side stitches begin to close the large tear defect.
Figure 9. An arthroscopic stitch passer and grasper are used to pass the sutures through the tendon ends.	Figure 10. An arthroscopic knot tying instrument is used to pass tie knots in the suture to secure the repair.
Figure 11. Small metallic anchors (5 mm) with sutures attached are then inserted into the humerus at the site desired for tendon reattachment. The anchors are recessed below the surface, so only the suture is visible.	Figure 12. The sutures may be permanent or resorbable, depending on the type chosen. Each anchor has 2 sutures to maximize tendon holding strength.

The sutures are once again passed through the tendon and systematically tied. The sutures pull the tendon right down to the prepared bone surface closing the defect. This completes the repair!

At the completion of the procedure, the shoulder is injected with a long acting local anesthetic to assist with postoperative pain management. Each portal incision is closed with a single nylon stitch and covered with steri-strip tapes, followed by a dry sterile dressing. A Cryocuff ^TM shoulder pad is applied to provide postoperative cold therapy. This assists in pain and swelling management. Finally a Don Joy Ultrasling II^TM is applied for immobilization and protection. The patient is then taken to the recovery room.

After Surgery

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