Rotator cuff surgery, our patients are in the upright, beach chair position. First we
point out the AC joint. Next, we point out the coracoid, an important landmark in shoulder
surgery. Now we point out the anterior lateral border of the acromion, the lateral border
of the acromion, and next we palpate our glenohumeral joint. Our fingers grasp the humeral head,
we next confirm the joint line with a spinal needle, and when it slides in easily, we use
a scalpel, make our incision through which we will insert the arthroscope. We use a metal,
blunt cannula, and insert this through the posterior capsule into the joint. We then
place our camera through this cannula and then we turn on our water supply. We are in
the joint and immediately create an anterior portal in the rotator interval with a spinal
needle. We are lateral to the coracoid. We make an incision and then insert our plastic
cannula. You see the orange tip coming through the tissue. We use this cannula to pass instruments
in and out of the joint. We start our diagnostic exam of the shoulder. Humeral head is to the
right and the glenoid is to the left. This is the anterior labrum, a little tattered,
but not detached. We slide into the axillary pouch. We then bring our camera up the back
of the glenoid, and now we visualize the long head of the biceps. We again focus on our
anterior labrum, and just to the right the thick band of tissue is the middle glenohumeral
ligament. Beneath the cannula was a subscapularis. We next use our shaver to debride and smooth
the rough edges of the anterior labrum, which showed some degenerative tearing. We next
maneuver our shaver above the long head of the biceps to the area of the rotator cuff
tear. We pause here. The anterior supraspinatus is torn and flipped immediately into the glenohumeral
joint. These torn edges are hypovascular and need to be debrided. We also need to remove
these torn edges to better evaluate our tendon tear. Now, as we continue with the shaver,
you clearly see the defect in the tendon much better as we progress.
It is not attached to the footprint of the greater tuberosity. You clearly see this area,
and a little more debridement with the shaver will help us completely prepare the undersurface
of the rotator cuff tear. We pause on the tear and you see the dark area to the right
is a small, crescent shaped rotator cuff tear, not attached. We next move to the subacromial
space and place the arthroscope in the space and we create a lateral portal. We insert
the same cannula and our shaver to perform a bursectomy. We begin our bursectomy. The
fluffy white tissue is the bursa, which we need to clean out in order to visualize. Just
above our shaver is the shiny white coracoacromial ligament, which is attaching to the anterior
lateral border of the acromion. This is the location of a spur. We next bring our cautery
device, which ablates soft tissue and is also capable of stopping any bleeding from the
bursa. Our shaver is then used again in the lateral gutter of the subacromial space. We
must clear out this bursal tissue, which is covering the bursal side of our rotator cuff
tear. To the right of our shaver, the pink tissue is our deltoid. When our bursectomy
is complete, we see our small rotator cuff tear. We must then prepare the edges of the
tear and the underlying bone for the rotator cuff repair. The shaver is actually inside
the tear, in the glenohumeral joint, and then lightly removing soft tissue from the underlying
bone of the greater tuberosity footprint. We need ablated surface for the tendon
to heal to. Here is a nice view of our one centimeter, supraspinatus tear, the underlying
yellow surface is the bone of the tuberosity. We must now localize the correct angle of
approach for our anchor. In the subacromial space, we confirm the spinal needle location,
we make a nick in the skin and insert our punch to make a pilot hole for the anchor.
We find the correct spot in the tuberosity, and then we mallet this punch down to the
black line that lets us now how far to go. Once our punch is all the way down, we insert
a tap to prepare the bone for the anchor. The small yellow globules you see are fat
from the bone. Once the tap is seated, we can remove the tap knowing our bone is prepared,
and we are ready to place our bioabsorbable anchor which you see here. We place this at
the same angle of approach into our prepared pilot hole. We seat the anchor at the black
line again, and then we pull on these sutures to assure the anchor is well seated in the
bone. We next must create an accessory portal again with a spinal needle, make a skin incision,
and then we insert another slightly larger black cannula you see here. We then use a
suture retriever and retrieve our first suture through the cannula. This is our suture lasso,
a metal device for shuttling suture through the tendon. We place it in the subacromial
space and pierce the rotator cuff tendon medial to the tear, assuring a good healthy bite
of tendon. We come out through the tear with the lasso, which is cannulated, and produces
a wire loop which we take out our accessory anterior portal. The suture awaits, we place
this in the loop, and we shuttle this back through the rotator cuff tendon as you see
here. We again use our retriever to take a blue and a white suture out our anterior cannula
again. We repeat the same step with our suture lasso, pulling onto the edge of the tendon
for tension, we pierce the tendon medical to the tear, produce our lasso, and again
we retrieve this lasso loop out our cannula. We shuttle our two sutures through the tendon.
Our grasper retrieves the last white suture and takes it out our anterior cannula. We again
pierce the tendon medial to the tear, posterior to our other sutures. We produce our lasso
and pull this again out our anterior cannula, we put the suture through the loop, you see
this here outside the body, and then we pull the suture through the loop and again into
the subacromial space, shuttling this through our rotator cuff tendon. All four sutures
are now through the tendon, and we must grasp corresponding sutures to tie our knot. Here
we took two white sutures, outside the cannula we are tying a special sliding knot called
the SMC knot. By pulling on one end of the suture, we know slide down into the subacromial
space our knot, and our knot pusher device pushes this knot firmly down onto the rotator
cuff, indenting the cuff nicely. We tie half hitches, which are multiple knots on top of
this knot, you see us tying outside the cannula, and this will really tighten the knot down
and cinch down the rotator cuff down to the anchor. When we are complete, we retrieve
our blue sutures as we have now placed the white sutures in another cannula to prevent
tangling. Once we have pulled these sutures outside the body, we again tie our same knot.
You see our knot pusher sliding the suture down to cinch the knot down firmly, which
is quite important. We next prepare for our lateral anchors. We need one of each suture,
one blue and one white, thus we retrieve these to load outside the body into our PushLock
anchors, which as you will see will firmly pull the tendon down over the footprint of
the greater tuberosity. We seat these anchors in the good lateral bone of the greater tuberosity.
Our punch feels and confirms the bone is solid, and we make a pilot hole as you see here.
We then place the loaded PushLock anchor into the pilot hole. Before we seat the anchor,
we pull the slack out of our sutures to assure the tendon is snug down. When we are pleased,
we seat our anchor, as you see, and we cut the ends of the suture. We then repeat this
step again with a next set of sutures, pulling them out the lateral cannula. Here you see
us loading them into the eyelet of the PushLock device. We again make a pilot hole in
the lateral cortex with a punch, a good one centimeter posterior to our other PushLock.
We then place our anchor into this hole, pull the slack out of our sutures, and when we
are satisfied, we seat our PushLock anchor. These anchors give us an interference fit
for the sutures laterally. They effectively create double row rotator cuff repair without
needing to place more anchors in the small greater tuberosity footprint. Here's our final
repair viewed from the lateral portal. See how the sutures are all tied medially in the
tendon and the ends are pulled over the lateral aspect of the tendon to this lateral row of
anchors. The tendon is pulled flush over the greater tuberosity footprint increasing the
surface area for tendon healing to bone. We internally and externally rotate the arm and
you can see a solid repair that is quite stable.