All-Intra-articular Arthroscopic Rotator Cuff Repair Pablo Ruben Rupenian, M.D.

Abstract: This Technical Note presents an arthroscopic technique to repair rotator cuff tears using a constant intraarticular (glenohumeral) portal for visualization. The smoothness of both the humeral head cartilage and the articular side of the rotator cuff offers a cleaner arthroscopic approach, while the absence of a subacromial bursa also reduces bleeding, turbidity, and the need for iterative soft tissue debridement. It also facilitates the recognition and repair of certain tear patterns. The intra-articular perspective allows the surgeon to visualize how stitches pierce the tissue in a desired and resistant area of the tendon. During knot tying, instead of watching the knot compressing against the bursal side of the tendon, the surgeon monitors how the articular side of the tendon is compressed and attached against the footprint while pushing the knot until the desired level of reduction is achieved.

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rthroscopic subacromial decompression was the first “technically demanding”1 step to abandon open rotator cuff repair. A few years later all-arthroscopic rotator cuff repair was successfully achieved while watching from a subacromial viewing perspective. Visualization and instrumentation in the subacromial space have certain inconveniences. Bleeding and turbidity tend to impede accurate visualization.2 Soft tissuedespecially a pathologic bursadfrequently interferes with an adequate field of vision. This scenario requires repetitive and tedious debridement that many times generatesdonce againdbleeding and turbidity. To bypass these issues, some surgeons choose to lower patients’ intraoperative blood pressurednot without running serious potential risksdand to increase arthroscopic fluid pump pressure leading to soft tissue swelling, portals shifting, and obliteration.2 The purpose of this Technical Note is to present an arthroscopic procedure that, using an all-intra-articular perspective, improves and simplifies not only visualization but also instrumentation during the repair of rotator cuff tears.

From the Sanatorio Modelo Quilmes, Buenos Aires, Argentina. The author reports that he has no conflicts of interest in the authorship and publication of this article. Received December 12, 2016; accepted February 27, 2017. Address correspondence to Pablo Ruben Rupenian, M.D., Paraguay 1896, 3rd Floor, C1121ABB, Buenos Aires, Argentina. E-mail: dr@ drpablorupenian.com Ó 2017 by the Arthroscopy Association of North America 2212-6287/161253/$36.00 http://dx.doi.org/10.1016/j.eats.2017.02.023

Technique Under interescalene brachial plexus block and light sedation, patients are placed in the beach chair position. A standard posterior glenohumeral viewing portal is created first. Joint exploration, dynamic assessment of the shoulder, and initial arthroscopic diagnosis are performed using a dry technique.3 Working portals vary between 2 and 3: 1 anterior and 1 lateral, 2 lateral, or 1 anterior and 2 lateral, depending on the size and/or pattern of the tear as well as the presence or absence of concomitant pathologies of the shoulder. In lieu of cannulas, we use hemicannulas (HALF PIPE [28728 LH], KARL STORZ, Tuttlingen, Germany) during the insertion of instruments or suture anchors.

Fig 1. Right shoulder. Posterior intra-articular viewing portal. Crescent-shaped full-thickness tear (asterisks) of the supraspinatus tendon. Notice the delaminated pattern and the reducibility of the deep articular retracted layer. (DL, deep layer; HH, humeral head; SL, superficial layer.)

Arthroscopy Techniques, Vol 6, No 3 (June), 2017: pp e901-e905

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Fig 2. Left shoulder. Posterior intra-articular viewing portal. (A) Dry arthroscopic vision of a partial-thickness articular side tear (arrow) of the supraspinatus tendon. The lesion in converted into a full-thickness tear with a scalpel (B), followed by debridement with a shaver (C) until healthy-looking tissue is found (D). (BT, biceps tendon; FP, footprint; HH, humeral head; ST, supraspinatus tendon.)

Fig 3. Right shoulder. (A) Posterior subacromial viewing portal. Partial-thickness bursal side tear (arrow) of the supraspinatus tendon. (B) Dry arthroscopic intra-articular perspective from a posterior glenohumeral viewing portal; notice the absence of pathologic correlation on the articular side (asterisk). (C) After turning this lesion into a full-thickness tear, a suture anchor is inserted while viewing from a posterior glenohumeral portal. (FP, footprint; HH, humeral head; ST, supraspinatus tendon.)

ALL-INTRA-ARTICULAR ROTATOR CUFF REPAIR

Fig 4. Right shoulder. Posterior intra-articular viewing portal. Footprint preparation with a shaver. (BT, biceps tendon; FP, footprint; HH, humeral head; ST, supraspinatus tendon.)

When dealing with full-thickness tears of the supraspinatus, infraspinatus, and/or teres minor tendons, we immediately start to assess the tear pattern as well as tendon mobility to plan the reconstruction (Fig 1). These initial steps are followed by debridement of any synovial tissuedif presentdand of any devitalized tissue at the free end of the torn tendon. Many full-thickness tears present concomitant, adjacent, articular side frayingdusually toward the posterior aspect of the rotator cuffdonly visible from an intra-articular perspective. We consider this damaged tissue as a possible cause of pain, so we resect it with the shaver up to a healthy-looking tendon (Video 1).

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In cases of any partial-thickness tear (articular side, bursal side, or interstitial) that requires repair, we first locate it by analyzing magnetic resonance imaging followed by the search of any suspicious fraying on the intra-articular side of the rotator cuff tendons with the arthroscope. After targeting the lesion using a needle by an outside-in technique, we turn it into a full-thickness teardfirst with a scalpel and then with a shaverduntil a healthy tendon is reached (Fig 2). In a few cases of small partial-thickness bursal side tears, we switch the arthroscope to the subacromial space, find the lesion, mark it with a needle, switch again into the intraarticular space, and proceed as aforementioned (Fig 3). The next step is the footprint preparation under direct visualization through the same posterior glenohumeral viewing portal (Fig 4; Video 1). In some cases, it is useful to abduct the shoulder during this part of the procedure. Double-loaded suture anchors are inserted under direct visualization (Fig 3C; Video 1). We are very cautious with suture management; before giving any stitch, we first hook the selected suture right from the footprintdusing a suture grasper or a hookdand retrieve the instrument to disentangle and separate that limb from the rest of the sutures. The same procedure is performed with the other limb of the suture before knot tying. Antegrade, retrograde, and side-to-side suturing are performed with any of the commercially available devices (Fig 5; Video 1). In most tear patterns, we use

Fig 5. Right shoulder. Posterior intra-articular viewing portal. (A) Anterior transverse tear (asterisk) of the supraspinatus at the midportion of the tendon. (B) Side-to-side repair (arrow). (C) Full-thickness supraspinatus tear in a right shoulder (different case). Antegrade suturing (asterisk) with a FirstPass (ArthroCare, Austin, TX) device. (HH, humeral head; ST, supraspinatus tendon.)

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Fig 6. Left shoulder. Posterior intra-articular viewing portal. (A) Small full-thickness anterolateral (asterisk) tear of the supraspinatus tendon. (B, C) Notice how a watertight repair (arrows) is achieved when knot pushing is monitored from the intraarticular portal. (BT, biceps tendon; HH, humeral head; ST, supraspinatus tendon.)

Clever Hook (T.A.G. Medical Products, Kibbutz Gaaton, Israel) and Penetrating Grasper (T.A.G. Medical Products) to give stitches, except in large retracted tears in which antegrade suturing with FirstPass (ArthroCare, Austin, TX) or shuttling 2-step technique using Spectrum Tissue Repair System (Conmed, Largo, FL) simplifies the procedure. The intra-articular perspective allows us to control how stitches pierce the tissue in a healthy-looking, resistant area of the tendon. It also facilitates the understanding, reduction, and repair of certain tear patterns such as retracted and/or delaminated tendon lesions (Video 1). For knot tying, we first introduce the knot pusher loaded with the suture post inside the joint to visualize that other sutures are not entangled. We then retrieve the knot pusher, give a half-hitch, and switch

the instrument to the subacromial space to start fixation. Intra-articular viewing during knot tying allows us to push the knots until a satisfactory and reliable contact between the tendon and the footprint is achieved (Fig 6).

Discussion All-intra-articular arthroscopic procedures for shoulder tendons have been universally accepted for a group of pathologies. By way of an example, we refer to the long head of the biceps tendon disorders, subscapularis tendon tears, PASTA (partial articular supraspinatus tendon avulsion) lesions, engaging Hill-Sachs lesions, among others.4-6 The glenohumeral joint offers a much more userfriendly working scenario than the subacromial space.

Table 1. Pearls and Pitfalls of the All-Intra-articular Arthroscopic Rotator Cuff Repair Technique Pearls

Pitfalls

The glenohumeral joint offers a user-friendly working scenario with a clear, unobstructed field of vision

The arthroscope sheath may injure the humeral head cartilage if the shoulder is not properly abducted while viewing at the tight posterolateral aspect of the rotator cuff Double row technique requires moving into the subacromial space to carry out the lateral row

The absence of a subacromial bursa also reduces bleeding, turbidity, and the need for iterative soft tissue debridement The intra-articular perspective facilitates the recognition and repair of certain complex tear patterns Intra-articular visualization facilitates stitching and suture retrieving through the tendon During knot tying, the surgeon monitors how the tendon is compressed and properly reduced against the footprint

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ALL-INTRA-ARTICULAR ROTATOR CUFF REPAIR

The clear and smooth cavity offered by the humeral head cartilage and the articular side of the rotator cuff tendons, coupled with the absence of bursal tissue, provides an almost-continuous unobstructed field of vision (Table 1). On the contrary, the subacromial spaceda gliding spacedmay result in an arduous, time-consuming, and frustrating working frame, especially in those frequent cases when a pathologic proliferative bursa is present. Many times, during traditional subacromial arthroscopy retrieving sutures after piercing the rotator cuff becomes a difficult surgical step because the tip of the penetrating instruments (i.e., Clever Hook, Spectrum, Penetrating Grasper) exits the tendon on the articular side while the surgeon observes with the arthroscope from the subacromial space. This is even more evident in the case of small tears. Although antegrade suture passing devices (i.e., FirstPass) are helpful to solve this inconvenience, they are many times unable to enter through small tears because of the significant size of these instruments. Intra-articular visualization from the wide glenohumeral cavity sets aside this suturingrelated difficulty. Other advantages of all-intra-articular rotator cuff repair are observed during knot tying. Using a glenohumeral viewing portal allows the surgeon to check the reduction of the tendon against the footprint until a watertight reduction is achieved (if possible). In addition, during subacromial arthroscopy, as the various stitches are knotted, the field of vision is progressively obstructed by the reattached rotator cuff; this is specially annoying from a lateral viewing portal. On the contrary, rotator cuff tendons move away from the glenohumeral viewing portal when sutures are tied. A limitation of the all-intra-articular technique is that when a double row repair technique is chosen, this requires moving into the subacromial space to carry out

the lateral row. Another issue would be that the humeral head cartilage may be injured by the sheath of the arthroscope while viewing at the tight posterolateral aspect of the rotator cuff. To avoid cartilage lesion the shoulder must be properly abducted during this part of the procedure. In summary, using an all-intra-articular arthroscopic technique, we are able to effectively explore, diagnose, and treat assorted conditions of the rotator cuff tendons. No additional skills or instruments are required, and we find ourselves working in a clear, comprehensive, and straightforward arthroscopic scenario.

Acknowledgment The author thanks Laura A. Rupenian for her supervision and advice in the preparation of this manuscript.

References 1. Ellman H. Arthroscopic subacromial decompression: Analysis of one to three year results. Arthroscopy 1987;3: 173-181. 2. Burkhart SS, Lo IKY, Brady PC. Visualization. In: Burkhart SS, Lo IKY, Brady PC, eds. Burkhart’s view of the shoulder. A cowboy’s guide to advanced shoulder arthroscopy. Philadelphia: Lippincott Williams & Wilkins, 2006;3-6. 3. Rupenian P. Dry arthroscopy of the shoulder. Arthrosc Tech 2013;2:e437-e440. 4. Burkhart SS, Tehrany AM. Arthroscopic subscapularis tendon repair: Technique and preliminary results. Arthroscopy 2002;18:454-463. 5. Spencer EE Jr. Partial-thickness articular surface rotator cuff tears: An all-inside repair technique. Clin Orthop Relat Res 2010;468:1514-1520. 6. Purchase RJ, Wolf EM, Smalley CC. Hill-Sachs “remplissage”: An arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy 2008;24:723-726.