This document discusses factors related to rotator cuff repair surgery. It addresses which tears require surgery and considerations around patient age. Key factors that affect healing are discussed such as tear size, retraction, and fatty infiltration. Guidelines are provided for managing tears in patients under and over 65. The steps of repair surgery are outlined, including assessment, preparation, anchor placement, suture passing techniques, and preferred repair techniques. Attention to set-up, visualization, and working within a standardized system are emphasized for success.

1. Rotator cuff repair
Mr Chris Roberts
Consultant Orthopaedic Surgeon
Ipswich Hospital
2nd Indian Watanabe meeting,
Chennai
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2. Cuff repairs
 Which cuff tears need
surgery and when?
 Does patient age matter?
 Which tears will progress?
 Pick winners.
 How to repair a tear.
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3. Age does matter
 Average age patients who heal 55
 Average age patients who do not heal 65
 Only 43% supraspinatus tears healed in patients
older than 65 c/w 85% under 65(Boileau)
 65 is correct cut off for aggressive vs
conservative management cuff tears (Yamaguchi
ICSES 2010)
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4. Which tears progress
 Maman
 More than 1 tendon
 Tear location - ant SST
 Duration of symptoms
 Moosmayer
 >3cm
 Yamaguchi
 Full > partial thickness
 21% asymp symp over 2 years
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5. Factors affecting healing
 Tear size and retraction
 Patient age
 Fatty infiltration (Goutallier grade)
 Tangent sign (Thomazeau)
 Smoking
 Marcaine
 Failure to load (Botox)
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6. Tears under 65
 Advise surgery
 New or sudden pain (= ? tear progression)
 >1.5cm
 Anterior column supraspinatus involved
 Else patient choice
 Conservative vs operative
 Injection reasonable but not >4 (Burkhead)
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7. Tears over 65
 Conservative initially
 Physiotherapy
 Activity modification
 Analgesia
 Injections
 Surgery if still symptomatic at 6 months
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8. Spectrum of pathology
 Impingement
 Partial thickness tears
 Full thickness tears
 Biceps lesions
 ACJ degeneration
 Cuff tear arthropathy
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9. Variables in cuff repair
 Biological:
 Extent and shape of tear
 Degree of retraction
 Quality of tendon
 Quality of muscle
 Quality of bone
 Mobility of tendon
 Healing of tendon to bone
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10. Steps in cuff repair
 GHJ arthroscopy
 Bursectomy/soft tissue clearance
 Tear inspection/type/reduction/mobilisation
 Cuff and bed preparation
 Anchor placement
 Suture passage
 Knot tying
 Acromioplasty?
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11. Work to a system
 Most tears can be repaired using a standardised
system so familiarise yourself with one
 Techniques needed:
 Knot tying
 Sliding and non-sliding
 Suture passage
 Antegrade and retrograde
 Repair type
 Footprint: single or double row
 Side to side
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12. Set-up
 Beach chair/lateral
decubitus
 Traction
 Hypotensive anaesthesia
 Shavers/burrs/radiofrequ
ency device
 Fluid management system
 Arthroscopic instruments
 Anchors/sutures
 Cannulae
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13. Portals
A
P
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14. GH Joint: Assessment of tear mobility
Medial-lateral reduction
QuickTime™ and a
decompressor
are needed to see this picture.
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15. Bursal View: Assessment of tear
mobility
QuickTime™ and a
decompressor
are needed to see this picture.
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16. Crescent-shaped Tears
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17. U-shaped Tears
 Firstly close side to side
 Then medial to lateral
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18. Margin Convergence
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19. Reducing The Cuff Tear:-
L-Shaped Tears
 L-Shaped Tears: (L-Shaped or Reverse-L)
Reverse-L Tear
S/Spinatus
Greater Tuberosity Greater Tuberosity
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20. L – Shaped Tears
L-shape Side-to- Fix to
side bone
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21. Assessment of tear pattern
QuickTime™ and a
decompressor
are needed to see this picture.
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22. NB!! Bursectomy (? SAD first)
QuickTime™ and a
decompressor
are needed to see this picture.
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23. Prepare footprint
QuickTime™ and a
decompressor
are needed to see this picture.
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24. Anchor Insertion
 Anchor fixation to bone
(Mahar,Arthroscopy 2006, 22)
 ‘Dead man’s angle of anchor insertion
(Burkhart, Arthroscopy, 95, 11)
QuickTime™ and a
decompressor
are needed to see this picture.
< 40 Deg
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25. Anchor Insertion:
‘Dead man Angle’ (Burkhart, 1995)
< 40 Deg
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26. Medial anchor insertion
QuickTime™ and a
decompressor
are needed to see this picture.
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27. Lateral row
QuickTime™ and a
decompressor
are needed to see this picture.
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28. Suture retrieval - retrograde
QuickTime™ and a
decompressor
are needed to see this picture.
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29. Suture Passing - retrograde
QuickTime™ and a
decompressor
are needed to see this picture.
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30. Suture Passing - antegrade
QuickTime™ and a
decompressor
are needed to see this picture.
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31. Suture Passing - shuttling
QuickTime™ and a
QuickTime™ and a decompressor
decompressor are needed to see this picture.
are needed to see this picture.
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32. Current Preferred Technique: ‘Suture-Bridge’
(Footprint Anchor for Lateral
Row)
•Medial anchor: pass sutures through cuff medially
and tie knots (increases tissue cut-out resistance)
Suture limbs inserted into 1 or 2 lateral footprint
anchors
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33. Footprint Anchor
•Standard medial row anchor(s)
and deep mattress sutures
•Don’t cut the sutures after tying
knots!!
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34. Conclusion
 Keys to success:
 Pick a winner
 Good anaesthesia
 Tension-free reduction
 Thorough bursectomy for visualisation
 Work to a system
 Variety of equipment invaluable
 My choice is Suture-bridge technique:
some evidence of improved
biomechanical strength
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