I'm Latul Farrow, Associate Professor of Sports Medicine at the Cleveland Clinic and Director of Sports Medicine Clinical Operations and the Program Director for the Orthopedic Sports Medicine Fellowship here at the Cleveland Clinic. I would like to thank our course organizers for allowing me to speak, and we're going to be talking about rotator cuff tears, small to large. I have nothing to disclose. Rotator pain is quite common, with over 4.5 million visits per year in the United States. This is only second to chronic knee pain as a cause for visits to physicians. And two-thirds of rotator cuff repairs are in working-aged individuals. This is an extremely important topic. Over 250,000 rotator cuff repairs per year in the United States, and this results in $1.5 trillion in healthcare costs, but on the flip side, amounts to $3.4 trillion a year in savings for the society. As we all know, there's nothing new under the sun. We all know this great quote from Codman about the difficulty there is with repairing rotator cuff tears. Dr. McLaughlin, many years ago, stated the importance, things that are required for successful rotator cuff repair. He noted that you need to obtain snug apposition of healthy tissues, avoid tension in the repair, restore continuity of the rotator cuff, make a watertight repair, and also respect the anatomy. Not much has changed with rotator cuff repair in current times. The goal is to restore function and or pain to pre-injury levels, restore the anatomy of the rotator cuff, and also to achieve full healing of the rotator cuff. What are the determinants of rotator cuff healing, anatomy, biomechanics, and biology? First we'll talk about anatomy. The key to a successful rotator cuff repair is really controlling what you can control, and there are times where because one of these three things, all of these three things, or some of these three things are involved, that maybe rotator cuff repair is doomed for failure. This is a rotator cuff repair from early in my career where we're failing on anatomy as we are lacking tendon substance, biomechanics are against us, and biology is also against us here. This is a patient that ultimately went on to re-tear the rotator cuff. So things that we can control, certainly anatomy. We can control biomechanics and biology, yes, but only sometimes. Let's define some terms. As we all know, single row does not always equal single row. Different definitions of single row include location of the anchor. This can be medial. It can be mid footprint or lateral. Stitch configuration can also vary as with respect to either single loaded suture being simple or mattress, or double loaded with two mattresses, or what I use commonly in modified mason island suture for our smaller tears. Whole row does also not equal double row. Classically the double row was seen as, arthroscopic double row was seen as medial and lateral tied sutures. This began to evolve with better techniques to tie medial row and then knotless lateral row and then the true transosseous equivalent where you either had tied or knotless medial row brought over to a knotless lateral row anchor system. This is a case presentation of a 41-year-old right-hand dominant laborer. Left shoulder pain and could not lift his arm, was involved in an ATV accident, had active elevation to 70 degrees, had the positive lag sign. No extent, pretty much diminished external rotation strength and a negative belly press. These are his MRI images. The image on the top shows the retraction of the rotator cuff tear to the hemorrhoid joint and some mild hemorrhoid elevation. And then we can see on the MRI, scrolling below, that he had a fairly sizable rotator cuff tear. So 41-year-old male, acute laborer, large acute rotator cuff tear. This is a no-brainer. This is not something that we're treating conservatively. This warrants surgical intervention. So what are keys to success? You want to know and respect your anatomy. Here are some of the traditional anatomy when we look at rotator cuff tears, rotator cuff anatomy, showing the superior outline of the supraspinatus tendon, the infraspinatus tendon, teres minor posteriorly and the subscapularis anteriorly. And even though this anatomy is seen to actually vary, this offers some guidance as to what we do in terms of defining rotator cuff size, as well as thinking about the anatomy. We see that the footprints are quite broad, anywhere from 16 to 20 millimeters or so in medial to lateral width. And then the actual longitudinal footprint of the rotator cuff, 23 millimeters of the supraspinatus and 29 millimeters at the infraspinatus. And we see how the relationship of the rotator cuff here with the supraspinatus, just off the articular surface, and then the infraspinatus just adjacent to the bare area. This here is a more elegant dissection of the shoulder showing that the supraspinatus and infraspinatus anatomy is quite variable. And here we see that there's some overlapping insertions of both the supraspinatus and infraspinatus. In some studies, the supraspinatus has actually been shown to not only cross the bicipital groove, but also insert along the lesser tuberosity. And likewise, the infraspinatus has been shown to wrap around and attach more anteriorly on the greater tuberosity, actually overlapping the supraspinatus tendon. We know that these footprints are wide and long. So when we look at restoring anatomy, this not only means restoring the relationship of the supraspinatus and infraspinatus involvement, but also restoring the actual anatomy of the footprint. In this laboratory study from the Journal of Shoulder Elbow Surgery in 2006, they looked at the analysis of single row versus double row fixation, and they found with single row fixation, about 46% of the rotator cuff footprint was covered with repair, but found that with double row repair, you had 100% coverage of the rotator cuff footprint. And the thought is this is important not only for healing, but also for creating a watertight seal and also biomechanic stability. So speaking of biomechanics, that's something else that certainly we can try to control. And why does it matter? Because we know that our patients don't always do what we ask them to do. In this study by Garstman, 200 consecutive patients were questioned at the first post-op visit and 20% admitted to having done something that may have compromised their repair. And we see this all the time. We know that ultimate level of failure is stronger with a double row repair. This has been shown by multiple studies. Also gapping has been shown to be quite decreased in shoulders with double row repair versus single row repair. What are the other thoughts about this? When you look at tendon compression between different double row techniques, traditional double row versus two medial row anchors and one lateral versus our two lateral anchors in the true trans-osseous equivalent, we can see on these images with the pressure sensitive film that the contact pressure is much improved with the trans-osseous equivalent. And we know that when you look at single row fixation, essentially it's just point fixation. So we see the advantages of recreating this footprint and using double row fixation. What about the fluid still at the repair site? This study by Ahmad et al in Journal of Shoulder and Elbow Surgery showed what double row fixation does with respect to fluid extravasation. And fluid is important because it's thought that the joint fluid can actually inhibit healing and certain things within the milieu of the joint can certainly lead to inflammation at the repair site and actually harm repair. So getting a good fluid seal is very important. And they found that double row repair significantly yields less fluid extravasation compared to other techniques. And we felt that this is partially, particularly better for repair site biology. Finally, the biology of healing. You can only control biology partially. We cannot control patient's age, we can't control things like smoking, but those are things that certainly may impact their healing. In this study by Tashian et al found that with older aged individuals, the healing of the rotator cuff is less. These are things that certainly we can't control a patient's age, but certainly things that you want to do in terms of counseling your patient. You know, with respect to the biology, again, control what you can control. You can control these things through biomechanics, you want to get decreased tendon-to-bone interface motion, you want to increase tendon compression, and you really want to get a fluid seal at the repair site. And back to our patient, 41-year-old labor, large rotator cuff tear and need for fixation. This is something that cannot wait. These should be fixed fairly urgently. You know, some of the literature says you can wait six to eight months to get to a rotator cuff, but I found that these can become very difficult to repair even as soon as two to three months after the injury. Patients begin to retract and get scarred in, and you can take what is a very mobile, easy to repair tissue, and make that retracted, contracted, and very difficult to repair. So these are patients that I really try to get into the operating room. And although, once in the operating room, you want to have a good plan for these patients, I perform rotator cuff surgery in a beach chair position because I think that's easiest in my hands to manipulate the shoulder with an arm holder with minimal assistance. But certainly, there are some literature out there to support that even for rotator cuff surgery, lateral position may have some benefits, but basically use whatever you're most comfortable with. I use multiple portals. Make as many portals as you need in order to obtain an excellent repair, and visualize the rotator cuff, manage your sutures, and make sure you're going to do the greatest job for your patients. So you want to get in there, and if needed, want to mobilize the cuff. Use either a shaver or a cautery device to get above and below the rotator cuff in order to mobilize this tissue. Here we can see in this patient, even though the rotator cuff tear is retracted, the edges of the rotator cuff have hematoma, and it's very apparent that this is more of an acute tear in this patient. You want to make sure you appreciate the anatomy. We see posteriorly that this is more of an L-shaped tear, where we kind of have our standard tear off the greater tuberosity, but then this also propagates medially in between the infraspinatus and the teres to form this L-shaped component. And so we place our first anchors off of the articular surface, and obviously this can be used with knotless or knotted anchors. It can also be used with either tape or regular suture, dealer's choice. You want to try to simplify the tear. So we see we have a margin convergent stitch posteriorly, so we're trying to make this from an L-shaped tear into a crescent-shaped tear, and then we can advance this down to the footprint. And for me, I place my anchors from anterior to posterior to make sure we have adequate coverage of the rotator cuff footprint and make sure we're advancing the tissues appropriately towards their anatomic attachment sites. You want to make sure you securely tie knots in the medial row. I think this helps me with tensioning, and then I want to tie from posterior to anterior. That goes from the area of least tension to most tension. And then I use a knotless lateral row, finally, to pull this down for a trans-osseous equivalent. And we can see in the picture up top, we've got excellent apposition of the rotator cuff, which was extremely mobile back to its footprint, and the picture below, once we stuck the scope back into the shoulder, we can see we have a tight anatomic seal of the rotator cuff down to the greater tuberosity. So what are the outcomes? Looking at re-tear rates in small to larger tears, small tears do well with double row and single row, and really there's not a huge advantage. The relative risk of re-tearing is not that great, but when you look at tears that are bigger in size, so more of your moderate to large tears, we found that single row has a much higher re-tear rate compared to double row. And so there is some evidence out there that states that double row is going to be best when approaching these rotator cuff tears. Three keys to success. You want to control the things that you can control. You want to visualize your anatomy, subtotal bursectomy. You want to get a good repair that allows for progressive postoperative rehabilitation. Ultimately, you want a tension-free repair, if possible. You want to be able to mobilize your soft tissues in order to do so, and then simplify complex tear patterns. Again, thank you for our course directors for allowing me to present. We look forward to a great course. Thank you.

rotator cuff tears

rotator pain

rotator cuff repair

anatomy

biomechanics