import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Exits quadrangular space with posterior humeral circumflex artery, wraps around surgical neck 5-7cm inferior to acromion at level of inferior glenohumeral ligament. **Protection**: Maintain lateral portal 5cm from acromion. Avoid inferior dissection beyond inferior capsule. Risk with inferior anchor placement or excessive inferior shaving. **Location**: Passes through suprascapular notch beneath superior transverse scapular ligament, runs 2-3cm medial to posterior glenoid rim in spinoglenoid notch, innervates supraspinatus then infraspinatus. **Protection**: Limit medial releases to 1cm medial to glenoid. Avoid aggressive medial dissection during mobilization. Use radiofrequency cautery away from medial border. **Location**: Enters coracobrachialis 3-8cm distal to coracoid tip (highly variable, as proximal as 2cm in 20% patients), runs between biceps and brachialis. **Protection**: Limit anterior portal dissection beyond conjoint tendon. Avoid anterior-inferior capsular releases. Risk with anterior portal placement or subscapularis repair. **Location**: Runs in deltopectoral groove between deltoid (lateral) and pectoralis major (medial), drains into axillary vein proximal to coracoid. **Protection**: If mini-open approach used, identify and retract laterally (with deltoid) or medially (with pectoralis). Injury causes hematoma and cosmetic defect. **Location**: Intra-articular origin from supraglenoid tubercle and superior labrum, exits through rotator interval between supraspinatus and subscapularis, travels in bicipital groove. **Protection**: Assess during glenohumeral arthroscopy for subluxation, partial tear. If pathologic (>50% tear, subluxation), perform tenotomy or tenodesis to prevent persistent anterior pain. ## Tear Size Classification (Cofield) ## Tear Pattern Classification ## Patte Retraction Classification ## Goutallier Fatty Infiltration Classification ## Rotator Cuff Footprint Anatomy **Supraspinatus Footprint**: - Location: Anterior facet of greater tuberosity (most superior aspect) - Dimensions: 15mm anteroposterior x 25mm superoinferior - Shape: Crescent-shaped insertion wrapping over superior humeral head - Biomechanics: Primary abduction initiator (0-90°), deltoid then dominant >90° - Blood supply: Critical zone 1cm medial to insertion (hypovascular Codman zone) **Infraspinatus Footprint**: - Location: Middle and posterior facets of greater tuberosity (inferior to supraspinatus) - Dimensions: 20mm anteroposterior x 25mm superoinferior (larger than supraspinatus) - Shape: Rectangular insertion on posterior-superior tuberosity - Biomechanics: External rotation primary, stabilizes humeral head, depresses during elevation - Innervation: Suprascapular nerve in spinoglenoid notch (at risk medial releases) **Cable-Crescent Concept**: - Cable: Thick perpendicular fiber bundle from biceps to infraspinatus (load-bearing) - Crescent: Thin area anterior to cable (tears initiate here, cable protects propagation) - Clinical: Anterior crescent tears common, posterior cable tears indicate massive damage ## Subacromial Space Anatomy **Boundaries**: - Superior: Undersurface of acromion, CA ligament, AC joint - Inferior: Superior rotator cuff (supraspinatus, infraspinatus insertions) - Medial: Base of coracoid and coracoacromial ligament medial attachment - Lateral: Deltoid muscle insertion and lateral humeral cortex **Contents**: - Subacromial bursa: Largest bursa in body, highly vascular (hemostasis critical) - Rotator cuff tendons: Supraspinatus (anterior), infraspinatus (posterior) - Long head biceps: Traverses anteriorly through rotator interval - Coracoacromial arch: Prevents superior humeral head migration (preserve in repair) **Acromion Morphology (Bigliani Classification)**: - Type I: Flat undersurface (10-15% population, lowest impingement risk) - Type II: Curved undersurface (40-50% population, moderate impingement risk) - Type III: Hooked anterior undersurface (30-40% population, highest impingement risk) - Clinical: Type III associated with cuff tears BUT acromioplasty does NOT improve repair outcomes ## Portal Anatomy and Safe Zones **Posterior Portal (Soft Spot)**: - Location: 2cm inferior and 1cm medial to posterolateral acromion corner - Trajectory: Anterosuperior and medial toward coracoid tip - Structures at risk: None if proper location (safe zone between infraspinatus and teres minor) - Technique: Palpate soft spot, trocar directed toward coracoid **Lateral Portal (Nevasier Portal)**: - Location: 2-3cm lateral to lateral acromion edge, aligned with posterior clavicle - Trajectory: Perpendicular to greater tuberosity (45° deadman angle for anchors) - Structures at risk: Axillary nerve if >5cm inferior to acromion - Critical importance: Primary working portal, determines anchor trajectory **Anterior-Superior Portal**: - Location: Through rotator interval between supraspinatus and subscapularis - Trajectory: Inside-out using spinal needle, 1cm anterior and 1cm lateral to anterolateral acromion - Structures at risk: Biceps tendon (identify and protect), musculocutaneous nerve if too inferior - Purpose: Accessory portal for suture management, anterior cuff visualization ## Single-Row vs Double-Row Comparison ## Suture-Bridge Technique (Double-Row Variant) **Concept**: Combination of medial row (simple or mattress sutures) plus lateral row (bridging sutures) creating compression across entire footprint **Advantages over Traditional Double-Row**: - Superior footprint compression (medial + lateral pressure zones) - Improved contact area (80-90% footprint coverage) - May reduce gap formation at medial row - Biomechanically strongest construct (failure load >500N) **Disadvantages**: - Most technically demanding, longest operative time - Highest cost (4-6 anchors required) - Risk of over-compression causing ischemia - No proven clinical superiority over single-row in RCTs **Current Indication**: Large-massive tears in high-demand patients (athletes, heavy laborers) where maximizing healing potential justified despite increased cost/complexity ## Margin Convergence Technique Details **Indications**: U-shaped, V-shaped, or large crescent tears with significant retraction **Technique**: 1. Identify medial and lateral leaves of tear after complete mobilization 2. Pass side-to-side horizontal mattress sutures using curved suture passer or straight needle 3. Place 2-4 convergence sutures spaced 1cm apart depending on tear size 4. Tie convergence sutures first, converting U-shape to crescent 5. Proceed with standard footprint repair (tension significantly reduced) **Biomechanical Benefit**: - Reduces strain on footprint repair by 30-40% - Decreases gap formation during ROM testing - Allows repair of otherwise irreparable large tears - Improved healing rates for U-shaped tears (70-80% vs 50-60% without convergence) **Pitfall**: Overtightening convergence sutures causes ischemia - goal is approximation not strangulation ## Medial Row Mattress Suture Options ## Landmark Studies **MOON Shoulder Group (2015) - Single vs Double-Row** - Multicenter RCT: 144 patients, 2-year follow-up - No difference: ASES scores, re-tear rates (24% single vs 20% double, p=0.54) - Conclusion: Single-row adequate for small-medium tears - Evidence Level: I (high-quality RCT) **Cochrane Review (2019) - Rotator Cuff Repair** - Meta-analysis: 37 RCTs, 3800 patients - Single vs double-row: No difference pain, function, ROM for tears <3cm - Double-row marginal benefit large tears (OR 0.62, p=0.04 for re-tear) - Recommendation: Single-row first-line, double-row selective for large tears **Galatz et al. (2004) - Natural History** - Prospective cohort: Full-thickness tears followed non-operatively - 50% progressed in size, 20% became symptomatic requiring surgery - Tear progression associated with: fatty infiltration, muscle atrophy, worse outcomes - Clinical impact: Early repair prevents progression, BUT many remain asymptomatic **Goutallier et al. (1994) - Fatty Infiltration** - Landmark CT classification of muscle degeneration - Grade 3-4 infiltration: 60% re-tear rate vs 15% Grade 0-1 - Fatty infiltration IRREVERSIBLE even after successful repair - Clinical: Assess pre-op MRI, high-grade infiltration = poor prognosis, consider alternatives **Boileau et al. (2005) - Arthroscopic vs Open** - RCT: 105 patients, arthroscopic vs mini-open repair - Equivalent outcomes: Constant scores, re-tear rates, ROM at 2 years - Arthroscopic: Less early pain, faster return to activities - Conclusion: Approach choice based on surgeon preference/expertise ## Rehabilitation Protocol Evidence **Keener et al. (2014) - Early vs Delayed Motion** - RCT: Early passive motion (2 weeks) vs delayed (6 weeks) - Delayed motion: Lower re-tear rate (15% vs 28%, p=0.04) - No difference in stiffness rates (8% both groups) - Recommendation: Delay passive ROM to 4-6 weeks for medium-large tears **Arndt et al. (2012) - Immobilization Position** - Biomechanical study: Abduction pillow vs conventional sling - 30° abduction reduces supraspinatus strain by 35% - Clinical trial: Lower re-tear with abduction (18% vs 26%, p=0.08) - Current practice: Abduction sling for medium-large tears, conventional for small **Thigpen et al. (2016) - Protocol Adherence** - Prospective cohort: Patient adherence to restrictions - Non-adherent patients: 3x higher re-tear risk (OR 2.9, p=0.01) - Most common violation: Early active ROM before 6 weeks - Clinical: Patient education critical, consider supervised therapy ## Australian-Specific Data **Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)** - Reverse TSA for massive irreparable cuff: 15% increase annually 2012-2022 - Failure rate cuff repair requiring revision: 8% at 5 years (increasing with age) - Age >70 with large tear: Primary reverse TSA outcomes superior to repair attempt - Recommendation: Lower threshold for reverse TSA in elderly with massive tears **Medicare Benefits Schedule (MBS) Item Numbers**: - Item 48909: Arthroscopic rotator cuff repair (single or multiple tendons) - $1,018 benefit - Item 48912: Open rotator cuff repair - $1,210 benefit - Item 48906: Shoulder arthroscopy (diagnostic) - $384 benefit - Item 48915: Arthroscopic subacromial decompression - $601 benefit - Clinical: Arthroscopic cuff repair reimbursed same single vs double-row (no added benefit for double-row) **Therapeutic Guidelines Antibiotic Prophylaxis (eTG)**: - Shoulder arthroscopy: Cephazolin 2g IV at induction - Penicillin allergy: Vancomycin 15mg/kg IV over 60 minutes - No indication for post-operative antibiotics (clean procedure) - Re-dosing: If procedure >4 hours or blood loss >1.5L ## Expected Outcomes by Tear Size **Key Outcome Predictors**: - Tear size: Strongest predictor of re-tear (small 10% vs massive 60%) - Age: >65 years higher re-tear risk (OR 1.8), slower recovery - Fatty infiltration: Goutallier 3-4 predicts failure (60% re-tear vs 15% Grade 0-1) - Smoking: Doubles re-tear risk (OR 2.1), impairs healing, advise cessation 6 weeks pre-op - Diabetes: Higher infection (3% vs 0.5%), slower healing, optimize HbA1c <7% - Workers compensation: Slower return to work, lower satisfaction (not necessarily worse clinical outcomes) ## Complication Management ## Failure Analysis and Revision Surgery **Causes of Repair Failure**: 1. Technical errors (40-50%): Inadequate mobilization, over-tensioning, poor footprint preparation, anchor malposition 2. Biological factors (30-40%): Poor tissue quality (Goutallier 3-4), elderly (>70 years), smoking, diabetes 3. Patient factors (20-30%): Non-compliance with restrictions, early active ROM, unrealistic high demands **Revision Repair Considerations**: - Assess tissue quality: If reasonable quality and correctable technical error, revision repair feasible (success 70-80%) - If poor tissue (fatty infiltration, thin degenerative tendon), revision likely to fail - consider SCR, patch augmentation, or reverse TSA - Revise technique: If single-row failed, consider double-row or suture-bridge for revision - Medialize footprint if lateral bone stock compromised from previous anchors - Informed consent: Revision has higher re-tear rate (30-40% vs 20% primary) **Patient Position**: Beach chair (preferred): head elevated 60-70°, arm in pneumatic holder (10-15lbs traction), slight abduction 20-30°, neutral rotation. Advantages: better arm mobility for assessment, easier conversion to mini-open if needed, more physiologic, easier anesthesia management. Disadvantages: hypotension risk (cerebral perfusion), fluid extravasation tracking to neck. OR Lateral decubitus: affected side up, 45° abduction in skeletal or skin traction, 20° forward flexion, 10-15lbs traction via pulley system, all bony prominences padded, beanbag positioning. Advantages: better superior visualization, less fluid extravasation, stable working field. Disadvantages: difficult conversion to open, traction neuropraxia risk, longer setup time. **Surgical Approach**: Arthroscopic technique utilizing posterior viewing portal, lateral (mid-lateral) working portal, anterior-superior (rotator interval) accessory portal. Subacromial space is primary working area. Standard 30° arthroscope (70° scope can help visualization of lateral footprint and medial cuff edge if needed). **Incision**: Three 5-8mm portal incisions: (1) Posterior portal 2cm inferior and 1cm medial to posterolateral acromion corner (soft spot), (2) Lateral portal 2-3cm lateral to lateral acromion edge aligned with posterior clavicle, (3) Anterior-superior portal through rotator interval via inside-out technique using spinal needle localization. **Equipment Required**: - Arthroscopy system: Camera, light source, fluid management pump (maintain 50-60mmHg pressure) - Arthroscopic instruments: Shavers (4.0mm aggressive, 5.5mm full-radius), radiofrequency device, burr, probe - Suture management: Penetrating suture passers (Spectrum, Scorpion, etc.), suture retrievers, suture graspers - Anchors: 2-4 double-loaded suture anchors (5.5mm knotless or 4.5mm knotted depending on bone quality) - Cannulas: 8mm threaded clear cannulas for portals (maintain working space, reduce soft tissue trauma) ### Step 1: Patient Setup and Portal Planning Patient Setup and Portal Planning: Position patient in beach chair at 60-70° with arm in pneumatic holder applying 10-15lbs traction (just enough to distract joint, excessive traction causes neuropraxia). Arm in 20-30° abduction (scapular plane), neutral rotation. Ensure proper head/neck positioning to prevent brachial plexus traction. Prep and drape entire shoulder, neck, arm to mid-forearm for full mobility. Mark anatomical landmarks with marker: acromion (anterior, lateral, posterior edges and corners), clavicle (medial, middle, lateral thirds), coracoid process, AC joint. Mark initial portal sites: posterior (soft spot - palpate depression 2cm inferior and 1cm medial to posterolateral acromion corner), lateral (to be refined but approximately 2-3cm lateral to lateral acromion in line with posterior clavicle), anterior-superior (to be determined via inside-out technique once intra-articular). Inject glenohumeral joint with 30-50ml saline with epinephrine (1:300,000) for joint distension (easier entry) and hemostasis (critical in vascular subacromial space). **Technical Tip**: EXAM KEY: 'I prefer beach chair positioning for rotator cuff repair as it allows better arm mobility for dynamic assessment of repair, easier conversion to mini-open if needed, and is more physiologic - easier for anesthesia to manage compared to lateral decubitus. The pneumatic arm holder provides gentle continuous traction (10-15lbs - just enough to distract the joint) and allows me to move the arm through ROM to test repair at the end. I inject epinephrine solution (1:300,000) into the joint for hemostasis which is absolutely critical for visualization in the highly vascular subacromial space - poor hemostasis is the enemy of arthroscopic surgery.' - Hypotension with beach chair position: Maintain cerebral perfusion, communicate with anesthesia, gradual positioning - Excessive traction causing neurologic injury: Keep traction <15lbs, check hourly, release periodically if long case - Poor portal planning limiting working space: Palpate landmarks carefully, mark portals before prep, visualize 3D trajectory - Brachial plexus injury: Avoid excessive head tilt or lateral neck flexion away from operative side ### Step 2: Posterior Portal & Diagnostic Glenohumeral Arthroscopy Posterior Portal & Diagnostic Glenohumeral Arthroscopy: Establish posterior portal at soft spot (2cm inferior, 1cm medial to posterolateral acromion corner) - palpate depression between infraspinatus and teres minor. Use #11 blade for skin incision, then blunt trocar directed toward coracoid tip to enter joint (aim anterosuperiorly and medially). Feel for pop as enter joint. Insert 30° arthroscope through trocar. Perform systematic 21-point glenohumeral examination: (1-2) Biceps origin at supraglenoid tubercle and intra-articular portion (assess for >50% partial tear, subluxation, instability, degenerative fraying), (3-4) Subscapularis from superior to inferior (assess for partial or complete tears, comma sign indicating complete tear, retraction), (5-7) Anterior labrum (SLAP tear, Bankart lesion, paralabral cyst), (8-9) MGHL and IGHL (capsular laxity, synovitis), (10-12) Humeral head cartilage (kissing lesion from impingement, chondral defects, AVN), (13-14) Glenoid cartilage (arthritis severity, bipolar kissing lesions, loose bodies), (15-16) Posterior labrum (posterior tear, posterior capsule), (17-21) Rotator cuff articular surface - supraspinatus footprint, infraspinatus, subscapularis upper border (assess for partial articular-sided tear PASTA lesion, full-thickness tear, crescent sign of exposed greater tuberosity indicating full-thickness). From articular view, assess tear: size (UNDERESTIMATED from articular side compared to bursal), location (anterior supraspinatus most common), tissue quality (thick vs thin, degenerative changes, margins), partial vs full thickness. **Technical Tip**: EXAM KEY: 'I perform systematic glenohumeral examination using a consistent pattern to assess concomitant pathology which occurs in 40-50% of rotator cuff tears and affects surgical plan. Critical findings that change management: (1) Biceps pathology - if >50% tear, subluxation, or Pulley lesion present, I perform tenotomy or tenodesis to prevent persistent anterior pain post-op. (2) Subscapularis tears - comma sign (subscapularis tendon retracted medial to biceps groove) indicates complete tear requiring repair. (3) SLAP tears - controversial in age >40, many advocate biceps tenotomy rather than labral repair. (4) Arthritis - if bipolar kissing lesions and significant cartilage loss, cuff repair alone will have poor outcomes, may need arthroplasty. From articular view, the CRESCENT SIGN (exposed greater tuberosity visible through tear) indicates full-thickness tear. Remember the articular-sided view UNDERESTIMATES tear size - the bursal side shows true extent.' - Missing partial articular-sided tear (PASTA lesion): Subtle finding, probe articular surface of cuff to assess - Missing subscapularis involvement: Look for comma sign, lift-off position, leads to failed repair if not addressed - Missing biceps instability/tear: Causes persistent anterior pain post-op if not treated (tenotomy/tenodesis) - Chondral damage from instruments: Maintain orientation, avoid excessive lever on cannula against glenoid/humerus ### Step 3: Lateral Portal Establishment & Subacromial Entry Lateral Portal Establishment & Subacromial Entry: Create lateral portal 2-3cm lateral to lateral acromion edge, in line with posterior border of clavicle (scapular plane). This is the KEY working portal - position is absolutely critical for perpendicular anchor trajectory to footprint. Use outside-in technique: under direct arthroscopic visualization from glenohumeral space (posterior portal viewing), insert spinal needle at marked lateral portal site. Aim needle tip toward glenohumeral joint first to verify trajectory under direct visualization - should enter joint through rotator interval superior to subscapularis. Once trajectory confirmed acceptable, withdraw needle and create skin incision with #11 blade. Insert switching stick through incision into glenohumeral joint, then advance to subacromial space. Exchange switching stick for 8mm threaded clear cannula. Move arthroscope camera from posterior portal to lateral portal (switch). Working instruments will now come through posterior portal. Initial viewing from lateral portal allows assessment of subacromial space while working posteriorly to enter and begin bursectomy. **Technical Tip**: EXAM KEY: 'The lateral portal is the KEY working portal for single-row repair and its position is absolutely critical for success. The optimal position is 2-3cm lateral to the lateral acromion edge, in line with the posterior clavicle which corresponds to the scapular plane. This position provides a PERPENDICULAR trajectory to the greater tuberosity footprint, allowing optimal anchor placement at the critical 45° deadman angle to the cortical surface. If the portal is too anterior, you cannot access the lateral footprint adequately. If too posterior, you cannot access the anterior cuff. If too inferior, you risk axillary nerve injury (<5cm from acromion is danger zone). I establish this portal from the glenohumeral space first using a spinal needle for precise localization, then transition to the subacromial space for better orientation - this two-step approach ensures accurate portal position.' - Portal too anterior: Difficult to access lateral footprint, poor anchor trajectory for posterior cuff - Portal too posterior: Difficult to access anterior cuff and rotator interval, limits working area - Portal too inferior (<5cm from acromion): Axillary nerve at risk as wraps around surgical neck at this level - Portal too medial: Cannot achieve perpendicular trajectory to footprint, oblique anchor angle reduces pull-out strength ### Step 4: Subacromial Bursectomy for Visualization Subacromial Bursectomy for Visualization: Enter subacromial space via lateral portal (camera now in lateral portal viewing subacromial space, working instruments via posterior portal). The subacromial bursa is the largest bursa in the body and is typically thickened, inflamed, and highly vascular in chronic rotator cuff tears. Perform COMPLETE bursectomy using motorized aggressive 4.0mm or full-radius 5.5mm shaver and radiofrequency ablation device for hemostasis. Work systematically in zones: Start anteriorly near CA ligament and work posteriorly, maintaining medial to lateral progression. Shave ALL bursal tissue to expose critical structures: (1) Undersurface of acromion from anterior to posterior, (2) CA ligament (medial border of subacromial space), (3) Rotator cuff tear from bursal side (true tear extent visible), (4) Greater tuberosity footprint (landing zone for repair). Use radiofrequency device liberally for hemostasis - any bleeding obscures visualization. Complete bursectomy is the single most important step for adequate exposure and is the FOUNDATION of successful arthroscopic rotator cuff repair. Poor visualization from incomplete bursectomy guarantees suboptimal repair. This step takes time (15-20 minutes) but cannot be rushed. **Technical Tip**: EXAM KEY: 'Complete bursectomy is the absolute foundation of successful arthroscopic cuff repair - I cannot overstate this. Poor visualization from inadequate bursectomy guarantees suboptimal repair because you cannot see the tear extent, footprint, or anatomy clearly. In chronic cuff tears, the bursa is massively thickened, inflamed, and vascular - it looks like angry red tissue obscuring everything. I systematically remove ALL bursal tissue using a shaver, working from anterior to posterior and medial to lateral. The radiofrequency device is essential for hemostasis - even small bleeding obscures the field in the fluid medium. Once complete bursectomy is done, I should have crystal-clear visualization of: (1) entire undersurface of acromion, (2) CA ligament medially, (3) the ENTIRE cuff tear from bursal side - which is often MUCH larger than it appeared from articular side, and (4) the greater tuberosity footprint where anchors will be placed. If I cannot see these structures clearly, bursectomy is incomplete. This takes 15-20 minutes but it's time well spent - it's the difference between a good repair and a poor repair.' - Incomplete bursectomy causing persistent poor visualization: Most common technical error, leads to suboptimal repair - Aggressive shaving damaging remaining cuff tissue: Balance complete bursectomy with preserving pathologic tissue, use shaver away from cuff edge - Inadequate hemostasis obscuring field: Liberal use of radiofrequency device, epinephrine in irrigation fluid, pump pressure 50-60mmHg - Suprascapular nerve injury: Avoid aggressive medial dissection >1cm medial to glenoid rim where nerve runs in spinoglenoid notch ### Step 5: Acromioplasty (if indicated) Acromioplasty (if indicated): Assess acromion morphology from subacromial viewing: Type I (flat undersurface - 10-15% population), Type II (curved undersurface - 40-50% population), Type III (hooked anterior undersurface - 30-40% population) per Bigliani classification. Also assess for anteroinferior osteophyte formation (traction spur from CA ligament). **CRITICAL CONCEPT**: The role of acromioplasty in arthroscopic rotator cuff repair is HIGHLY CONTROVERSIAL. Historical teaching advocated routine acromioplasty for subacromial impingement. However, modern high-quality evidence (RCTs and meta-analyses) shows that acromioplasty does NOT improve outcomes in most rotator cuff repairs - the tear is due to intrinsic tendon degeneration and failure, NOT extrinsic mechanical impingement. Current recommendation: Perform MINIMAL acromioplasty - only if significant Type III hook or large anteroinferior spur causing mechanical block to motion. If performing acromioplasty: Use arthroscopic burr to flatten undersurface, remove anteroinferior 3-5mm creating FLAT Type I morphology. Start anteriorly and work posteriorly in passes. Goal is smooth gliding surface for cuff, NOT over-resection. Preserve CA ligament attachment medially (recent studies show CA ligament is important restraint to superior humeral migration - excessive release weakens this). Remove any osteophytes from greater tuberosity as well (improves footprint preparation). **Technical Tip**: EXAM KEY: 'The role of acromioplasty in arthroscopic cuff repair is one of the most CONTROVERSIAL topics in shoulder surgery. The traditional teaching was routine acromioplasty for impingement. However, modern evidence has completely challenged this. Multiple RCTs including the landmark UKUFF trial (2018, 313 patients) showed NO difference in outcomes between cuff repair with vs without acromioplasty - same pain scores, same function, same satisfaction at 2 years. The key insight is that rotator cuff tears are caused by INTRINSIC tendon degeneration and failure (age-related, genetic, vascular), NOT extrinsic mechanical impingement from acromial morphology. Therefore, I perform MINIMAL or NO acromioplasty in most cases - only if there is a significant Type III hook or large anteroinferior spur that would cause mechanical block. My goal if I do perform acromioplasty is to flatten the undersurface to Type I morphology by removing 3-5mm anteroinferiorly. Over-resection risks: (1) Deltoid origin injury causing pain and weakness, (2) Acromion fracture, (3) Weakened CA arch allowing superior escape. The key message: Acromioplasty is NOT a routine part of cuff repair - it's selective based on bony morphology.' - Over-aggressive acromioplasty: Deltoid detachment from origin, acromion stress fracture, weakened CA arch, unsightly deltoid depression - Anterior acromion over-resection: Cosmetic deltoid depression anteriorly (visible defect), anterior instability if excessive CA ligament release - Inadequate decompression if significant Type III morphology: If large hook present and not addressed, may cause mechanical impingement - Damaging AC joint: Stay 1cm from AC joint during anterior acromioplasty to avoid iatrogenic AC arthritis ### Step 6: Tear Pattern Assessment and Mobilization Tear Pattern Assessment and Mobilization: After complete bursectomy and any acromioplasty, perform detailed assessment of rotator cuff tear from bursal side using arthroscopic probe. Assess FIVE critical parameters: (1) **TEAR SIZE**: Measure using probe or arthroscopic ruler - Small <1cm, Medium 1-3cm, Large 3-5cm, Massive >5cm (Cofield classification). Remember bursal view shows TRUE size (articular view underestimates). (2) **TEAR PATTERN**: Crescent (linear tear parallel to footprint, minimal retraction), L-shaped (longitudinal split with lateral retraction creating L), U-shaped or V-shaped (retracted medial and lateral leaves creating U/V), Massive contracted (>5cm, retracted to glenoid, poor excursion). (3) **TISSUE QUALITY**: Thick robust tissue vs thin degenerative tissue, friable vs healthy margins, presence of extensive degeneration. (4) **RETRACTION**: Patte classification - Stage 1 (tendon edge near anatomic insertion), Stage 2 (retracted to humeral head apex), Stage 3 (retracted to glenoid level - often irreparable). (5) **FATTY INFILTRATION**: Estimate based on pre-operative MRI Goutallier grading - Grade 0 (normal) to 4 (>50% fat). Grade 3-4 predicts high failure rate 40-60%. After assessment, proceed with MOBILIZATION which is CRITICAL for tension-free repair: Release adhesions on superior surface (to acromion), medial border (to glenoid - CAREFUL of suprascapular nerve 2-3cm medial), lateral border, bursal side. For U-shaped tears, perform MARGIN CONVERGENCE (side-to-side sutures to approximate leaves, converting U to crescent - reduces footprint strain by 30-40%). For large retracted tears, consider INTERVAL SLIDES: Anterior interval slide (release between supraspinatus and subscapularis anteriorly), Posterior interval slide (release between supraspinatus and infraspinatus posteriorly). The GOAL of mobilization: Tendon must reach the lateral footprint with the arm at the side WITHOUT excessive tension. Test by grasping tendon with instrument and pulling to footprint - should reach easily. If cannot mobilize tendon to footprint despite maximal releases and slides, tear is IRREPARABLE - consider partial repair, superior capsular reconstruction (SCR), patch augmentation, or reverse TSA. **Technical Tip**: EXAM KEY: 'Tear pattern assessment determines the entire repair strategy - this is a critical decision point. CRESCENT tears (most common, ~60%) have direct linear tear parallel to footprint with minimal retraction - these get direct repair to footprint with single or double-row, simplest repair. U-SHAPED tears (~25%) have retracted creating medial and lateral leaves - these MUST have margin convergence FIRST (side-to-side sutures) to approximate the leaves and convert to crescent shape, then footprint repair. If you try to repair U-shaped tear directly to footprint without margin convergence, it will be under massive tension and WILL fail - margin convergence reduces strain 30-40%. L-SHAPED tears (~10%) have longitudinal split with lateral retraction - repair the apex FIRST with corner stitch to capture maximal tissue, then repair edges. MASSIVE tears (>5cm) often cannot be fully repaired - consider partial repair to cover humeral head, SCR, or reverse TSA in elderly. Mobilization is absolutely CRITICAL - this is the most important technical step. I release ALL adhesions: superior (to acromion), medial (to glenoid, careful of suprascapular nerve 2cm medial), lateral, bursal. The marker of adequate mobilization: tendon reaches lateral footprint with arm at side WITHOUT tension. Inadequate mobilization causing repair under tension is the #1 preventable technical error leading to failure. If the tendon won't reach the footprint even after maximal mobilization (Patte Stage 3 retraction), it's irreparable - forcing a repair under massive tension guarantees failure.' - Inadequate mobilization causing repair under tension: #1 preventable technical error, leads to high failure rate, must release all adhesions - Aggressive mobilization damaging poor quality tissue: Balance needed, aggressive releases in thin degenerative tissue can extend tear - Suprascapular nerve injury during medial releases: Nerve runs 2-3cm medial to posterior glenoid in spinoglenoid notch, limit medial dissection, use radiofrequency away from nerve - Forcing repair of irreparable tear: If Patte Stage 3 + Goutallier 3-4 + won't mobilize to footprint, accept it's irreparable, consider alternatives ### Step 7: Greater Tuberosity Footprint Preparation Greater Tuberosity Footprint Preparation: Identify the greater tuberosity footprint which is the anatomic insertion site for supraspinatus and infraspinatus tendons. **Supraspinatus footprint**: Anterior facet of greater tuberosity (most superior), dimensions 15mm anteroposterior x 25mm superoinferior, crescent shape. **Infraspinatus footprint**: Middle and posterior facets (inferior to supraspinatus), dimensions 20mm AP x 25mm SI, rectangular shape. The footprint extends from the articular margin medially (intra-articular) to the lateral edge of the greater tuberosity laterally. Prepare footprint systematically: (1) Remove soft tissue, fibrous scar tissue, and granulation tissue using shaver and radiofrequency ablation device to expose cortical bone, (2) Decorticate using motorized burr or rasp to create BLEEDING bone bed with punctate bleeding from cancellous bone - this provides bone marrow vascular access for biological healing. **CRITICAL CONCEPT**: The goal is LIGHT decortication - expose cancellous bone with punctate bleeding, but do NOT create deep bony trough or large defect. Over-aggressive decortication (creating trough >5mm deep) WEAKENS the bone and increases risk of anchor pull-out failure and fracture. Create roughened vascular surface 3-5mm wide at lateral footprint edge. Mark the medial border (articular margin - do not place anchors medial to this or will be intra-articular causing chondral damage). Preserve lateral bone stock (this is where anchors will be placed). The footprint should show punctate bleeding but maintain structural integrity. **Technical Tip**: EXAM KEY: 'Footprint preparation optimizes the biological healing environment for tendon-to-bone healing. The traditional teaching was aggressive decortication creating a trough - this is WRONG and causes more harm than good. I use a shaver and radiofrequency device to remove all soft tissue, scar, and granulation tissue from the footprint to expose bone. Then I perform GENTLE decortication with a burr - just enough to create punctate bleeding from cancellous bone marrow. This bleeding provides vascular access and growth factors for healing. The key concept is LIGHT decortication - if you create a large deep trough (>5mm), you WEAKEN the bone substantially and the anchors will pull out. Multiple biomechanical studies show over-decortication reduces pull-out strength by 40-60%. My goal is a roughened vascular surface 3-5mm wide with punctate bleeding, NOT a deep trough. The footprint is the anatomic insertion of the rotator cuff - I aim to restore anatomy by repairing tendon to native footprint, which extends from articular margin medially to lateral greater tuberosity edge laterally. In single-row repair, anchors are placed at the LATERAL EDGE of the footprint near the articular margin-lateral junction.' - Over-aggressive decortication creating deep trough: Weakens bone dramatically, anchor pull-out, humeral head fracture risk, reduces pull-out strength 40-60% - Inadequate preparation leaving soft tissue: Poor biological healing environment, fibrous interposition, lower healing rates - Medializing footprint excessively (intra-articular anchor placement): Chondral damage to humeral head, joint penetration, articular cartilage injury - Fracture of greater tuberosity: Risk in osteoporotic bone if over-burring, especially in elderly or rheumatoid patients ### Step 8: Suture Anchor Placement - Single Row Configuration Suture Anchor Placement - Single Row Configuration: In SINGLE-ROW technique, anchors are placed at the LATERAL EDGE of the prepared footprint near the articular margin-lateral junction. This position balances biomechanics and biology: provides anatomic footprint restoration, maximizes tendon-bone contact area, and ensures adequate bone stock for purchase. Determine number of anchors based on tear size: Small tears <1cm need 1-2 anchors, Medium tears 1-3cm need 2-3 anchors spaced 5-8mm apart, Large tears 3-5cm need 3-4 anchors. Use double-loaded suture anchors (each anchor has 2 sutures = 4 suture limbs total per anchor). Select anchor size based on bone quality: 4.5mm anchors for good bone, 5.5mm for osteoporotic or poor bone. **Anchor insertion technique - DEADMAN ANGLE**: This is the single most important technical concept for anchor placement. The anchor must be inserted at 45° angle to the cortical bone surface (perpendicular to the footprint slope). This 45° deadman angle engages BOTH cortical bone at the surface AND cancellous bone deep, providing maximum pull-out strength. If angle <45° (too oblique), anchor loses cortical purchase and pulls out easily. Insert anchor via lateral working portal for optimal trajectory perpendicular to footprint. Technique: (1) Use drill guide or freehand to create pilot hole at planned anchor position, (2) Tap anchor hole to appropriate depth (some anchors self-tapping), (3) Insert anchor to proper depth - flush with cortex or 1mm proud (varies by anchor design), (4) Test anchor security with gentle pull - should be rock solid, (5) Color-code sutures for organization (e.g., blue=anterior, white=posterior). Typical configuration for 2-anchor medium tear: Anchor #1 at anterior footprint, Anchor #2 at posterior footprint, spaced 8-10mm apart, both at 45° deadman angle. **Technical Tip**: EXAM KEY: 'Single-row anchor position and insertion technique are critical for success. The anchors are placed at the LATERAL EDGE of the footprint, which corresponds to the junction between the articular margin and lateral greater tuberosity - this is approximately 5-7mm lateral to the cartilage edge. This position restores anatomic footprint coverage and maximizes tendon-bone contact for healing while ensuring adequate bone stock for anchor purchase. The DEADMAN ANGLE is the single most important concept: anchors must be inserted at 45° to the cortical surface. This angle engages the strong cortical bone at the surface plus the cancellous bone deep, providing maximum pull-out strength. Biomechanical studies show 45° provides 40-50% greater pull-out resistance compared to 90° perpendicular or <30° oblique angles. The lateral working portal provides the optimal trajectory - perpendicular to the footprint from lateral approach. I insert anchors via lateral portal using the drill guide aligned at 45° angle, tap the hole, then insert anchor to appropriate depth (flush or 1mm proud depending on design). I test each anchor with gentle pull before proceeding - the anchor should be absolutely rock solid. If any question about anchor security, I remove and place new anchor in different position. For a typical medium tear, 2-3 double-loaded anchors (8-12 suture limbs total) provide adequate fixation. I color-code sutures to prevent tangling: blue sutures = anterior anchor, white sutures = posterior anchor.' - Anchor too medial (intra-articular placement): Penetrates joint, chondral damage to humeral head, articular cartilage injury - Anchor too lateral (insufficient bone stock): Lateral cortex is thin, fracture risk, inadequate purchase, pull-out - Poor deadman angle (<45°): Loses cortical engagement, reduces pull-out strength 40-50%, anchor migration and failure - Anchor proud (>2mm above cortex): Subacromial impingement symptoms, prominent knot catching on acromion - Anchor pull-out during testing: Indicates poor bone quality or technique, must place new anchor different location ### Step 9: Suture Management and Passage Preparation Suture Management and Passage Preparation: After anchor insertion, immediately retrieve and organize suture limbs to prevent tangling (tangled sutures are the most frustrating technical complication and can add 20-30 minutes to case). Technique: Use suture grasper or retriever via anterior-superior portal to retrieve suture limbs from subacromial space. Organize sutures systematically by anchor and color: Anchor #1 (anterior) - separate blue suture limbs via different portals (one limb through anterior portal, one through lateral portal), Anchor #2 (posterior) - separate white suture limbs. Pass different colored sutures through different cannulas to maintain separation and prevent tangling. Typical organization for 2-anchor repair: Anterior anchor blue sutures (Limb A through anterior cannula, Limb B through lateral cannula), Posterior anchor white sutures (Limb C through anterior cannula, Limb D through lateral cannula). Alternative technique: Some surgeons shuttle ALL sutures to anterior portal for passage (requires more manipulation but centralizes suture passage). Plan suture passage pattern through cuff: Will use mattress configuration (both limbs of each suture pair pass through tendon separated by 5-10mm). Ensure sutures are untangled before proceeding to passage - test by gently pulling each limb individually, should move freely without catching others. **Technical Tip**: EXAM KEY: 'Suture management and organization is absolutely critical to avoid the most frustrating technical complication in arthroscopic cuff repair - TANGLED SUTURES. Once sutures tangle in the joint, it can take 20-30 minutes of frustrating work to untangle them, or you may have to cut and replace anchors (nightmare scenario). Prevention is key: immediately after EACH anchor insertion, I retrieve and organize those sutures before placing the next anchor. I color-code by anchor: blue = anterior anchor, white = posterior anchor. I pass different colored sutures through different portals to physically separate them: blue limb A through anterior cannula, blue limb B through lateral cannula, white limb C through anterior cannula, white limb D through lateral cannula. This physical separation prevents tangling. Before suture passage, I test each limb individually - pull gently, should slide freely without catching other sutures. If any binding, stop and reorganize. The time spent on careful suture management (5-10 minutes) saves massive frustration later. Some surgeons prefer to shuttle all sutures to the anterior portal which centralizes suture passage, but requires more suture manipulation. Either technique works if systematic and organized.' - Suture tangling: Most common and frustrating technical complication, can add 20-30 minutes, may require cutting and anchor replacement - Lost suture limb in joint: Falls into joint space, requires retrieval with grasper, time-consuming - Cutting suture on cannula edge: Sharp cannula edges can fray or cut sutures during manipulation, use threaded clear cannulas - Disorganized sutures causing confusion: Must maintain clear mental map of which suture belongs to which anchor and where it will pass ### Step 10: Suture Passage Through Rotator Cuff Tendon Suture Passage Through Rotator Cuff Tendon: Pass sutures through rotator cuff tendon using penetrating suture passing devices (options: Spectrum with Penetrator device, Arthrex Scorpion, Smith & Nephew BirdBeak, Stryker OPUS, or other systems). These devices combine a grasping element with a needle to pierce tissue, grasp suture, and retrieve in one motion. **Suture configuration**: MATTRESS sutures are strongly preferred over simple sutures because mattress provides superior tissue purchase (more tendon captured) and reduces cut-through risk in degenerative tissue. Technique: For each anchor, pass both limbs of one suture pair through tendon as horizontal mattress - First pass: insert suture passer from bursal to articular side (or vice versa depending on device) 5-10mm from tear edge (not too close or sutures cut through, not too far or tendon bunches), grasp one suture limb, retrieve back through tissue. Second pass: insert passer 5-10mm lateral to first pass (parallel to tear edge), grasp second suture limb of the pair, retrieve. This creates horizontal mattress configuration with both limbs through tendon separated 5-10mm. Ensure adequate TISSUE BITE - at least 5-8mm of healthy tendon captured with each pass. Avoid friable or severely degenerative areas - choose thicker healthier tissue when possible. For 2-anchor repair with mattress sutures, you'll make 4 total passes through the tendon (2 passes per anchor). Space the suture passage sites 5-8mm apart to distribute load. Assess tissue security after passage - sutures should have solid purchase in tissue, not loose or sliding through easily. **Technical Tip**: EXAM KEY: 'Suture passage is technically demanding and requires good three-dimensional understanding of anatomy. MATTRESS sutures are the standard for single-row repair because they provide much better tissue purchase compared to simple sutures - this is critical in degenerative rotator cuff tissue which is prone to cut-through. The mattress configuration captures more tendon substance (5-10mm width vs single point for simple) and distributes force over larger area, reducing suture pull-through. I pass sutures 5-10mm from the tear edge - this is the sweet spot: too close (<5mm) and sutures cut through the edge, too far (>10mm) and the tendon bunches up creating a medial overhang of tissue that doesn't contact bone. Adequate tissue bite is absolutely critical - I ensure at least 5-8mm of healthy tendon is captured with each pass. The penetrating suture passing devices (Spectrum Penetrator, Scorpion, BirdBeak) make this easier - they pierce through tissue, grasp the suture limb, and retrieve in one smooth motion. I prefer bursal-to-articular passage direction as it's easier to visualize the articular exit and ensure good tissue purchase. After passage, I assess tissue security - the sutures should have solid purchase with no sliding or loose feeling. If sutures are loose or cut through during testing, I re-pass in thicker tissue. The quality of suture passage directly determines repair strength and failure rate.' - Suture passage too close to tear edge (<5mm): Sutures cut through tissue during tensioning, #1 cause of suture pull-out failure - Inadequate tissue bite (<5mm of tendon): Weak fixation, gap formation at repair site, poor load distribution, early failure - Passing through poor quality degenerative tissue: Friable areas won't hold sutures, avoid thin degenerative zones, choose thicker tissue - Iatrogenic cuff tear extension from passage device: Sharp passing devices can extend tear if not careful, use blunt first, control device - Articular-side suture passage injury: Exiting articular side can damage cartilage if misdirected, visualize exit clearly ### Step 11: Knot Tying - Securing Repair Knot Tying - Securing Repair: Tie knots to complete repair and secure tendon to bone. **Sequence**: Tie knots systematically from ANTERIOR to POSTERIOR (or posterior to anterior - consistency is what matters) to prevent tangling and maintain control. For each anchor's mattress suture: Retrieve both limbs of the suture pair via the same cannula (typically lateral or anterior portal for tying), ensure no tangling or crossing of sutures. Use sliding-locking knot technique: **SMC knot** (sliding-locking, most common), **Revo knot**, or **surgeon's sixth finger** for arthroscopic tying. Knot technique: (1) Create initial sliding knot on post limb, (2) Advance knot using knot pusher while maintaining tension on both limbs, (3) TIGHTEN POST-LIMB FIRST to create slide (pull post limb to slide knot down to tissue), (4) Lock knot by tightening wrapping limb, (5) Add 3 half-hitches in ALTERNATING directions for backup security (prevents knot slippage). **CRITICAL CONCEPT - APPROPRIATE TENSION**: This is the art of rotator cuff repair. The instinct is to over-tighten to get solid tendon-bone contact. However, OVER-TIGHTENING is the #1 technical error causing failure. Excessive tension creates tissue ischemia (tendon blanches white), necrosis, and suture cut-through. The goal is GENTLE approximation of tendon to bone - not drum-tight repair. Biological healing provides long-term strength, NOT knot tension. Assess each tied knot visually: tendon should be touching bone without gap, but should NOT be blanched white (indicates ischemia), no excessive bunching. Tie all knots for all anchors sequentially. Cut suture tails with arthroscopic scissors leaving 2-3mm tails (long tails cause irritation, flush cut can slip). Bury prominent knots by rotating slightly with probe if impinging on acromion. **Technical Tip**: EXAM KEY: 'Knot tying is where science meets art in arthroscopic surgery. I use the SMC sliding-locking knot which is secure, reproducible, and well-studied. The technique: slip the post limb first to slide the knot down to tissue, then lock with half-hitches in alternating directions (3 half-hitches minimum for security). The CRITICAL concept that examiners test is APPROPRIATE TENSION - this is the #1 technical error in rotator cuff repair. The surgeon's natural instinct is to crank down on the knots as tight as possible to get solid contact - this is WRONG and causes failure. Over-tightening creates several problems: (1) Tissue ischemia - the tendon blanches white which means blood supply is cut off, leading to necrosis and failure, (2) Suture cut-through - excessive tension causes sutures to cheese-wire through degenerative tissue, (3) Gap formation - ischemic tissue dies and gaps develop. The key insight: the repair does NOT need to be drum-tight because BIOLOGICAL HEALING provides the long-term strength, not knot tension. My goal is gentle approximation - the tendon should be touching bone with no gap, but should maintain pink healthy color indicating perfusion. I assess each knot: tendon touching bone (no gap), pink color (not white/blanched), no excessive bunching. Some studies suggest accepting 1-2mm gap is better than over-tensioning - the biology will fill small gaps but cannot recover from ischemia. I tie systematically from anterior to posterior to prevent suture tangling, cut tails to 2-3mm (long enough not to slip, short enough not to irritate), and bury any prominent knots.' - Over-tensioning repair: #1 technical error, causes tissue ischemia (blanched white tendon), necrosis, suture cut-through, failure - Under-tensioning: Persistent gap >2mm, poor tendon-bone contact, delayed/impaired healing, requires careful balance - Knot slippage: Use locking configuration with minimum 3 alternating half-hitches, test security before cutting - Knot prominence: Prominent knots impinge on acromion causing pain, bury by rotating with probe, consider knotless anchors for prominent cases - Cutting post limb first: Knot can slip if cut post before locking, always cut non-post limbs first, post last ### Step 12: Repair Assessment and ROM Testing Repair Assessment and ROM Testing: After tying all knots and completing repair, perform comprehensive assessment to confirm adequate repair before closing: (1) **VISUAL ASSESSMENT**: Camera view from multiple portals (lateral and posterior viewing) - Tendon should be approximated to footprint across entire repair, Coverage of greater tuberosity by tendon, No residual gaps >2mm at tendon-bone interface, No excessive bunching or medial tissue overhang, Knots secure and not overly prominent. (2) **PROBE TEST**: Use arthroscopic probe to gently test repair integrity - Probe between tendon and bone (should be NO gap with gentle probing), Gentle traction on repair (should be stable without gapping), Firm tissue-bone contact throughout, If repair easily gaps with gentle probing, inadequate - consider additional sutures or re-tying with different tension. (3) **DYNAMIC ROM TESTING**: This is the most important assessment. Remove arm from pneumatic traction. Take arm through passive ROM - Forward flexion to 90° then 120°, Abduction in scapular plane to 90°, Gentle internal and external rotation. WATCH THE REPAIR continuously during motion: repair should remain intact without gapping, if repair gaps with normal passive ROM, it is UNDER EXCESSIVE TENSION and will fail post-operatively. If excessive tension noted: Options are (a) re-tie knots looser accepting small gap (biology will heal), (b) accept medialized footprint repair (healing 5-10mm medial to lateral edge - recent literature suggests this may be biomechanically advantageous with lower re-tear rates), (c) convert to double-row if tissue allows, (d) if irreparable, consider partial repair, SCR, or reverse TSA. The repair does NOT have to be perfect - it has to be biologically viable meaning adequate blood supply and reasonable tension. **Technical Tip**: EXAM KEY: 'The final repair assessment is critical and the dynamic ROM testing is the most important part - this tells me if the repair will survive post-operatively. First, I perform visual assessment from multiple viewing portals: the tendon should be covering the footprint nicely without large gaps, no excessive bunching medially, knots secure and not overly prominent. Second, I probe the repair gently - should be firm contact between tendon and bone with no easy gapping. If the probe easily creates a gap, the repair is inadequate. Third and most important: DYNAMIC ROM TESTING. I remove the arm from traction and take it through gentle passive ROM - forward flexion to 120°, abduction to 90°, rotation. While doing this, I watch the repair continuously with the arthroscope. The repair should remain intact throughout normal ROM. If the repair GAPS with normal passive motion, this is a red flag - it means the repair is under too much tension and will fail when the patient starts therapy. If I see gapping with ROM, I have several options: (1) Accept medialized repair - recent studies show medialized footprint repair (healing 5-10mm medial to lateral edge) may actually have LOWER re-tear rates and better biomechanics than anatomic lateral repair, possibly because of reduced tension, (2) Re-tie knots slightly looser accepting 1-2mm gap - biology will heal small gaps but cannot overcome ischemia, (3) Convert to partial repair accepting that complete anatomic repair is not achievable. The key concept: the perfect-looking repair under traction that gaps with normal ROM will fail. Better to have a slightly imperfect repair that's biologically viable.' - Accepting inadequate repair that gaps with gentle probing: Will fail, need additional sutures or re-tensioning - Accepting over-tensioned repair that gaps with normal ROM: Will fail post-operatively when PT starts, must adjust before closing - Missing residual tear at margin: Perform complete 360° inspection of entire cuff, look for tears at subscapularis-supraspinatus junction anteriorly or supraspinatus-infraspinatus junction posteriorly - Inadequate footprint coverage: If large lateral or medial gap, may need additional anchors or accept partial repair ### Step 13: Margin Convergence (if needed for U-shaped tears) Margin Convergence (if needed for U-shaped tears): If U-SHAPED or V-SHAPED tear pattern was identified during initial assessment (Step 6), margin convergence should be performed BEFORE or DURING the footprint anchor repair. **Tear pattern**: U-shaped tears have retracted creating distinct medial and lateral leaves separated by a gap - the tear looks like a U or V shape rather than linear crescent. **Why margin convergence is essential**: Direct repair of U-shaped tear to footprint without convergence would place the repair under MASSIVE tension because the two leaves are separated - this guarantees failure with re-tear rates >60%. Margin convergence reduces strain on the footprint repair by 30-40% by first approximating the leaves. **Technique**: (1) Identify medial and lateral leaves of the U-shaped tear after complete mobilization, (2) Pass side-to-side horizontal mattress sutures using suture passing device (or free straight needle) - pierce through lateral leaf from bursal to articular side, cross gap, pierce through medial leaf articular to bursal, retrieve both limbs, (3) Place 2-4 convergence sutures depending on tear size, spaced 1cm apart along the gap, (4) Tie convergence sutures FIRST before anchor repair - this approximates the leaves and converts the U-shaped tear into a crescent shape, (5) Proceed with standard footprint anchor repair (now under much less tension). **Biomechanical benefit**: Studies show margin convergence reduces peak strain at footprint repair by 35-40%, reduces gap formation during ROM by 50%, and improves healing rates for U-shaped tears from 50-60% without convergence to 75-85% with convergence. **Pitfall**: Do NOT over-tighten convergence sutures causing central tissue ischemia - goal is approximation not strangulation. **Technical Tip**: EXAM KEY: 'Margin convergence is a critical technique for U-shaped tears and the examiner will test whether you recognize when it's needed. U-shaped tears occur when the tendon retraction creates medial and lateral leaves separated by a gap - if you look at the tear from bursal side it literally looks like a U or V. The key insight is that direct repair of this U-shaped tear to the footprint WITHOUT margin convergence would place the repair under massive tension as you're trying to close a U-shaped gap - this will fail almost guaranteed with re-tear rates >60% in studies. Instead, margin convergence technique first approximates the two leaves side-to-side (closing the U), converting it to a crescent shape, THEN you repair to footprint. This reduces the strain on the footprint repair by 30-40% which is biomechanically significant. I perform margin convergence BEFORE anchor placement: pass horizontal mattress sutures side-to-side across the gap (lateral leaf to medial leaf), place 2-4 convergence sutures spaced 1cm apart, tie these first to close the U into a crescent, then proceed with standard single-row anchor repair to footprint. The repair is now under much less tension and has much higher success rate. The key pitfall is over-tightening the convergence sutures which causes central ischemia - I want approximation of leaves but not strangulation. Margin convergence is one of the most important adjunctive techniques in rotator cuff repair and transforms irreparable U-shaped tears into reparable crescent tears.' - Attempting direct repair of U-shaped tear WITHOUT margin convergence: Massive tension on footprint repair, guaranteed high failure rate >60% - Inadequate convergence leaving persistent gap: Incomplete conversion to crescent, residual tension, benefit lost - Over-tightening convergence sutures: Central tissue ischemia and necrosis, tissue damage, weakening of repair - Missing U-shaped pattern during assessment: Perform careful initial assessment of tear pattern, look for separated leaves ### Step 14: Hemostasis and Final Inspection Hemostasis and Final Inspection: After completing repair and all assessments, ensure hemostasis before closing. Use radiofrequency ablation device or epinephrine-soaked neurosurgical cottonoid sponge pressed against bleeding areas. Small venous oozing is acceptable (will tamponade with pressure dressing). Larger arterial bleeding or vigorous venous bleeding requires control to prevent post-operative hematoma (increases infection risk and inflammation). Perform final systematic 360° inspection of entire surgical field: **Glenohumeral joint** (switch back to GH viewing): No loose bodies or suture fragments in joint, No iatrogenic chondral damage to humeral head or glenoid, Biceps tendon intact if preserved (or tenotomy/tenodesis completed if indicated), Subscapularis intact (no iatrogenic injury from anterior portal). **Subacromial space**: Repair intact and secure across entire footprint, No prominent knots causing impingement on acromion (bury if needed), No residual loose tissue or bursal remnants, No residual bony prominences if acromioplasty performed. **Portals**: No skin bridges between portal sites (maintain 2cm separation minimum to prevent necrosis), Adequate hemostasis at portal sites. Irrigate copiously with 3-6 liters normal saline or lactated Ringer's solution to remove debris, bone fragments, and blood clot - this reduces post-operative inflammation and infection risk. Consider intra-articular injection of local anesthetic (0.25% bupivacaine 20-30ml) and/or corticosteroid (controversial - some studies suggest impairs healing, others show improved pain control) into subacromial space and glenohumeral joint for immediate post-operative pain control which facilitates early passive ROM therapy. **Technical Tip**: EXAM KEY: 'The final inspection is systematic and I inspect both glenohumeral and subacromial compartments completely before closing. I'm looking for several critical things: (1) Repair integrity confirmed - tendon covering footprint, secure knots, no residual gaps, (2) No loose sutures or knot fragments in joint - these cause clicking, pain, synovitis, and chondrolysis if left behind, (3) No iatrogenic chondral injury to humeral head or glenoid from instruments - document if present as can affect outcomes, (4) Adequate hemostasis - small oozing acceptable but large bleeding needs control to prevent hematoma, (5) No prominent knots causing impingement - I test by moving arm through ROM and watching for catching. I irrigate copiously with 3-6 liters of fluid - this is important for washing out debris, bone fragments, blood clot, and inflammatory mediators which reduces post-op inflammation and infection risk. Some surgeons use antibiotic-impregnated irrigation (controversial, not standard). I infiltrate the subacromial space and portals with 0.25% bupivacaine (long-acting local anesthetic) for post-operative pain control - this is very helpful for patient comfort in the first 12-24 hours and facilitates early gentle passive ROM. The use of intra-articular corticosteroid is controversial: older teaching advocated routine steroid injection, but recent studies suggest steroids may impair tendon healing - I generally avoid steroids in cuff repair. The final inspection takes 5 minutes but prevents complications.' - Missed loose suture or knot fragment in joint: Causes clicking, pain, synovitis, chondrolysis (cartilage damage), requires removal - Uncontrolled bleeding causing hematoma: Post-operative hematoma increases infection risk 3-4x, causes pain and inflammation - Prominent knot causing impingement: Persistent post-operative pain, clicking, catching, may require arthroscopic removal - Iatrogenic chondral injury not documented: Can affect outcomes, important to document if occurred for patient understanding ### Step 15: Portal Closure and Immobilization Portal Closure and Immobilization: Remove all instruments and cannulas under direct visualization to ensure no loose sutures caught on instruments. Close portals: Posterior and lateral portals (larger, deep penetration) with 3-0 nylon simple interrupted or horizontal mattress sutures, Anterior-superior portal (smaller) with 4-0 nylon or absorbable 4-0 monocryl for better cosmesis. Apply sterile dressings: Xeroform or adaptic over incisions, 4x4 gauze, waterproof dressing (Tegaderm or similar). Apply compressive wrap around shoulder (ACE wrap or abdominal pad) for hemostasis and to reduce fluid extravasation swelling - not too tight (check neurovascular status). **IMMOBILIZATION - Critical for Repair Protection**: Place arm in ABDUCTION SLING with neutral rotation. The standard abduction sling has abduction pillow that holds arm at 30-45° abduction in scapular plane - this position REDUCES tension on supraspinatus repair compared to arm at side (adducted position). Biomechanical studies show 30° abduction reduces supraspinatus strain by 35% compared to 0° (arm at side). Recent clinical studies suggest abduction immobilization may improve healing rates for medium and large tears. Alternative: Simple sling acceptable for small tears, but abduction pillow preferred for medium-large tears. The arm should be immobilized in position of MINIMUM tension on repair. AVOID internal rotation which increases anterior supraspinatus tension. Patient education is absolutely critical at this time: Sling must stay on 24 hours per day for first 6 weeks except for gentle passive exercises with therapist (no active motion, no weight bearing). Non-compliance with immobilization is major cause of re-tear - emphasize this. Provide written instructions. Schedule follow-up at 2 weeks for wound check, 6 weeks for sling removal and active ROM, 3 months for strengthening progression. **Technical Tip**: EXAM KEY: 'Immobilization position and post-operative patient compliance are absolutely critical for protecting the repair during the healing phase. I use an abduction sling with abduction pillow that holds the arm at 30-45° abduction in the scapular plane (plane of scapula, about 30° anterior to coronal plane). This position of abduction REDUCES tension on the supraspinatus repair compared to arm at side - biomechanical studies show 35% reduction in supraspinatus strain at 30° abduction vs 0°. The mechanism is that abduction relaxes the supraspinatus muscle-tendon unit reducing pull on the repair. Recent clinical studies suggest abduction immobilization may improve healing rates particularly for medium and large tears: one RCT showed 18% re-tear with abduction sling vs 26% with conventional sling (not statistically significant but trending). I use abduction sling routinely for medium and large tears, and conventional sling is acceptable for small tears. The critical message to patient: the sling stays on 24/7 for 6 weeks except for gentle supervised passive exercises (no active motion). Patient non-compliance with this restriction is a MAJOR cause of re-tear - studies show 3x higher re-tear rate in non-compliant patients. I spend significant time educating patient and family: no reaching, no lifting, no active shoulder motion for 6 weeks. The repair is strong enough for gentle passive motion to prevent stiffness but NOT strong enough for active muscle contraction - that comes at 6-8 weeks. I provide written instructions and emphasize consequences of early active motion (re-tear requiring revision surgery). Schedule follow-up: 2 weeks wound check, 6 weeks sling removal and start active ROM, 3 months strengthen, 6 months unrestricted.' - Skin bridge necrosis if portals too close: Maintain 2cm minimum separation between portal incisions, blood supply enters from sides - Early mobilization by non-compliant patient causing re-tear: #1 preventable cause of failure, patient education critical, written instructions - Excessive immobilization causing stiffness: Balance needed - must protect repair 6 weeks but start gentle passive ROM at 2-4 weeks to prevent adhesive capsulitis, particularly in diabetics - Neurovascular injury from tight immobilizer: Check radial pulse, neurologic function after applying sling, should not be compressive - Portal site infection: Rare but devastating, instruct patient on wound care, watch for erythema/drainage/fever, low threshold for evaluation **PHASE 1 (0-6 weeks) - PROTECTION PHASE**: This is the most critical phase for repair healing. **Immobilization**: Abduction sling with 30° abduction pillow worn 24 hours/day, remove only for exercises and hygiene. Sleep in sling. No active shoulder motion, no weight bearing with operative arm. **Passive ROM only** (therapist-guided or with opposite arm): Pendulum exercises (Codman) starting day 1 (gravity-dependent gentle oscillations), Passive forward flexion in supine position (supine table slides) starting week 2 - progress to 90° by week 4, progress to 120° by week 6, Passive external rotation in scapular plane with arm at side starting week 2 - progress to 30° by week 6 (do NOT force, respect tissue), Passive internal rotation gentle (hand to abdomen) week 4-6, NO active elevation, NO resisted exercises. Elbow/wrist/hand active ROM throughout to prevent stiffness and swelling. **Goals**: Protect healing repair (most vulnerable 0-6 weeks), prevent stiffness (gentle passive motion sufficient). **Rationale**: Tendon-bone healing requires 6-8 weeks for fibrovascular scar formation. Active muscle contraction generates high forces (up to 500N) that exceed repair strength in early phase, causing gap formation or re-tear. Passive motion generates minimal forces (<50N) and is safe to prevent adhesions. **PHASE 2 (6-12 weeks) - ACTIVE MOTION PHASE**: **Immobilization**: Wean from sling week 6-8, transition to sling for comfort and protection in crowded areas. Discontinue sling by week 8. **Active-assisted ROM** starting week 6: Pulleys, cane exercises, wall walks for forward flexion and abduction (patient provides some active muscle contribution), Progress to full active ROM by week 8-10 (patient lifts arm independently without assistance). **Active ROM against gravity** week 8-12: Forward flexion, abduction, rotation without weight/resistance. **Light isometrics** week 10-12: Gentle muscle contractions without motion (submaximal effort). **Goals**: Restore full active ROM (should achieve forward flexion 150-160°, abduction 160°, external rotation 60°, internal rotation to T10 by week 12), Initiate muscle activation and prevent atrophy. **Rationale**: By 6-8 weeks, repair has sufficient strength for active motion (fibrovascular scar formed). Progressive loading stimulates healing. Active ROM required for functional recovery. **PHASE 3 (12-16 weeks) - STRENGTHENING PHASE**: **Active ROM against gravity** all planes. **Progressive resistance exercises** starting week 12: Theraband (light resistance), progress to 1-2lb weights, advance to 3-5lbs by week 16. Focus on rotator cuff strengthening (external rotation, internal rotation), scapular stabilizers (rows, protraction), deltoid. **Proprioception training**: Closed-chain exercises, perturbation training. **Goals**: Restore strength (target 80% of contralateral side by week 16), Improve neuromuscular control and dynamic stability. **PHASE 4 (16-24 weeks) - RETURN TO ACTIVITY PHASE**: **Progressive functional strengthening**: Sport-specific or work-specific exercises, Plyometrics for athletes, Heavy resistance training (5-10lbs+). **Return to Activities of Daily Living**: Light ADLs 3-4 months, Unrestricted ADLs 4-6 months. **Return to Sport/Heavy Labor**: Non-contact sports 4-6 months, Contact sports 6-9 months, Heavy overhead labor 6-9 months. **Full recovery**: 6-12 months for complete healing and maximal strength recovery. **Tear Size Affects Timeline**: Small tears (<1cm) can progress faster (active ROM at 4-6 weeks, strengthen at 8-10 weeks). Medium tears (1-3cm) follow standard protocol above. Large tears (3-5cm) need prolonged protection (passive only 0-8 weeks, active 8-12 weeks) due to higher re-tear risk and slower healing. **Monitoring**: Clinical follow-up at 2 weeks (wound check, passive ROM assessment), 6 weeks (remove sling, initiate active ROM), 3 months (assess ROM and strength, advance strengthening), 6 months (functional assessment, return to sport clearance). MRI not routine unless clinical concern for re-tear (return of pain/weakness, positive lag signs). Re-tear diagnosed by MRI showing full-thickness defect, fluid signal, tendon retraction. Asymptomatic re-tears can be observed (10-15% have MRI re-tear without symptoms). Symptomatic re-tears require decision: revision repair if good tissue and compliance, versus SCR/reverse TSA if poor tissue or elderly. ## References 1. **Colvin AC, Egorova N, Harrison AK, Moskowitz A, Flatow EL.** National trends in rotator cuff repair. J Bone Joint Surg Am. 2012;94(3):227-233. doi:10.2106/JBJS.J.00739 - Landmark epidemiology study showing dramatic increase in arthroscopic cuff repairs (141% increase 1996-2006) and shift from open to arthroscopic technique, establishing arthroscopic repair as standard of care. 2. **Duquin TR, Buyea C, Bisson LJ.** Which method of rotator cuff repair leads to the highest rate of structural healing? A systematic review. Am J Sports Med. 2010;38(4):835-841. doi:10.1177/0363546509359679 - Systematic review of repair techniques showing double-row biomechanical advantages but NO clinical superiority for small-medium tears, fundamental evidence supporting single-row as first-line. 3. **Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K.** The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004;86(2):219-224. doi:10.2106/00004623-200402000-00002 - Seminal study establishing that structural healing (intact tendon on ultrasound) does NOT always correlate with clinical outcome - pain relief and function improved even with re-tears, paradigm shift in understanding cuff repair outcomes. 4. **Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC.** Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;(304):78-83. - Landmark classification of fatty infiltration predicting repair outcomes - Grade 3-4 infiltration associated with 40-60% re-tear rate and poor functional recovery, critical pre-operative prognostic tool referenced in all modern cuff repair studies. 5. **Keener JD, Galatz LM, Stobbs-Cucchi G, Patton R, Yamaguchi K.** Rehabilitation following arthroscopic rotator cuff repair: a prospective randomized trial of immobilization compared with early motion. J Bone Joint Surg Am. 2014;96(1):11-19. doi:10.2106/JBJS.M.00034 - Prospective RCT showing delayed passive motion (6 weeks) associated with LOWER re-tear rate (15% vs 28%, p=0.04) compared to early motion (2 weeks) with NO difference in stiffness rates, evidence supporting prolonged immobilization for medium-large tears. 6. **Gladstone JN, Bishop JY, Lo IK, Flatow EL.** Fatty infiltration and atrophy of the rotator cuff do not improve after rotator cuff repair and correlate with poor functional outcome. Am J Sports Med. 2007;35(5):719-728. doi:10.1177/0363546506297539 - Critical study demonstrating fatty infiltration is IRREVERSIBLE even after successful repair, establishing Goutallier grading as key prognostic factor and shifting understanding of cuff tear pathophysiology from mechanical to degenerative process. 7. **Park MC, ElAttrache NS, Tibone JE, Ahmad CS, Jun BJ, Lee TQ.** Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. J Shoulder Elbow Surg. 2007;16(4):461-468. doi:10.1016/j.jse.2006.09.010 - Biomechanical study establishing suture-bridge (transosseous-equivalent) provides superior footprint coverage (80% vs 60% double-row vs 40% single-row) and contact pressure, foundational biomechanics supporting modern double-row techniques for large tears. 8. **MOON Shoulder Group. Unruh KP, Kuhn JE, Sanders R, et al.** The duration of symptoms does not correlate with rotator cuff tear severity or other patient-related features: a cross-sectional study of patients with atraumatic, full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2014;23(7):1052-1058. doi:10.1016/j.jse.2013.10.001 - MOON Shoulder Group prospective cohort establishing that symptom duration does NOT correlate with tear size, retraction, or fatty infiltration, challenging traditional teaching about early repair to prevent tear progression, nuanced understanding of surgical timing. 9. **Mihata T, Lee TQ, Watanabe C, et al.** Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy. 2013;29(3):459-470. doi:10.1016/j.arthro.2012.10.022 - Landmark study introducing superior capsular reconstruction (SCR) technique as alternative to reverse TSA for irreparable cuff tears, showing 88% good-excellent results and significant improvement in active elevation, expanding surgical options for young patients with irreparable tears. 10. **Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Hip, Knee & Shoulder Arthroplasty: 2022 Annual Report.** Adelaide: AOA; 2022. - Australian registry data showing 15% annual increase in reverse total shoulder arthroplasty for rotator cuff arthropathy 2012-2022, 8% failure rate for cuff repair at 5 years increasing with age, evidence supporting lower threshold for primary reverse TSA in elderly (>70 years) with massive irreparable tears over attempted repair.

Arthroscopic Rotator Cuff Repair - Single Row Technique

Arthroscopic Rotator Cuff Repair - Single Row Technique