Bridging Reconstruction Techniques for Rotator Cuff Tears

“Doc, I think I tore my rotary cup.” If you work in orthopedics, you have likely heard something like this before. The anatomic term is the Rotator Cuff–but what actually is the rotator cuff? How is a cuff tear repaired? I will share one way that I repaired a rotator cuff tear using many strong tape sutures. The rotator cuff is made of 4 separate tendons that attach to the top of the humerus or arm bone. These four tendons and their respective muscles are often remembered by students with the acronym SITS: supraspinatus, infraspinatus, teres minor, and subscapularis tendons. There are two main types of rotator cuff tears: degenerative and acute tears. We know from Dr. Yamaguchi’s JBJS study from 2006 (and many others) that rotator cuff disease correlates with age–these tears are like the wear and tear of your favorite pair of jeans because you’ve worn them out. Both conservative and surgical treatment can be an option for degenerative tears. The other type of tear is an acute or sudden tear, usually from an injury or accident. Young patients can often have acute tears from falls, sports, or possibly work activities. These are very different than degenerative tears. Research by Gutman et al (JSES 2021) showed that early repair of these acute tears optimizes outcomes. Tears like we see in this patient can be challenging to repair. This tear was in a patient under age 50 that is very active. This tear occurred acutely. Repair was recommended. The footprint on the greater tuberosity was gently decorticated with the shaver to encourage bone-tendon healing. I prefer to use a four-anchor double row repair for tears of this size using the Stryker AlphaVent Knotless anchors. The medial vented anchors were double-loaded to allow for force distribution for the sutures passed through the rotator cuff tissue. The double-row construct also optimizes footprint compression. Key for success: two passing-loop sutures were secured in luggage tag fashion to augment the repair and one eyelet suture was also passed to enhance anterior compression. These additional sutures prevent “dog-ears” and offer additional compression of the tendon to the bone. A 2020 study published in AJSM by Urch et al (including Dr. Thay Lee) analyzed the biomechanics of the additional luggage tag sutures; their results demonstrated improved contact pressure of the rotator cuff tissue on the bony footprint in the specimens that had the additional luggage tag sutures. The patient was started on a passive-only gentle PT program for the 1st six weeks, with further focus on active motion and strengthening to follow with the subsequent phases of PT. The residents and fellows at the Orlando Health Jewett Orthopedic Institute have frequent opportunities to see arthroscopic management of tears like these.

Margin convergence sutures One of the keys to success in #rotatorcuff repair is a tension-free construct. A common failure mode is cutting the suture through the tendon. We can prevent this by using the technique of margin convergence sutures, which was popularized by Stephen S. Burkhart twenty years ago. The principles he described are still valid and often forgotten, so it is good to recall them (https://lnkd.in/eRseeFdJ). Margin convergence sutures allow us to benefit from the good anterior-to-posterior mobility of the rotator cuff tear margins while also acting as rip-stop stitches. In the video you can see how subscap reapir and 4 margin convergence sutures dramatically reduced the size of this massive tear and allowed us to perform a simple #transosseous repair. The result was a tension-free construct and an excellently healed patient with full shoulder function today.

Here’s a true Transosseous hybrid repair at 6 months. This technique uses all transosseous fixation at footprint for cerclage with a single anchor backup if the surgeon thinks that is necessary. This creates triple row fixation construct without relying on the lateral row knotless anchor which can fail the entire construct of an all knotless approach. More fixation point density/ cost, better revision considerations by avoiding type 2 failure and not creating bone voids. Note the homogenous T1 signal of tendon when the biomechanics are matched rather than exceeded. #rotatorcuff #shouldersurgery https://lnkd.in/eEfCRzu