Hi. My name is Lucas Teske, and I'll be presenting on rotator cuff repair. We'll discuss the double-row rotator cuff repair and management of partial rotator cuff tears. Let's start with indications, techniques, and pitfalls to the double-row rotator cuff repair. Multiple studies have evaluated double versus single-row rotator cuff repair. Consensus is that there's no difference in patient-reported outcomes between the two groups. However, reasonable evidence suggests lower re-tear rate and stronger repair constructs in a double-row repair. Therefore, my preference is for double-row repair if the cuff can be returned to its anatomic footprint and without extensive tension. I will start by sharing my technique and a few pearls I've learned along the way. First, we need to prepare for success. That comes down to controlling soft tissue swelling and optimizing your visualization. The biggest key is to minimize the violation of the deltoid fascia. Once the fascia loses its continuity, fluid will start to infiltrate the extra-fascial deltoid muscles and the walls begin to close. Controlling the pump pressure and utilization of cannulas will help maintain the integrity of the fascia. You'll also need to be efficient. One of my mentors used the phrase, the longer it takes, the longer it takes. Superficially, it sounds like Yogi Berra talking, but realistically, the longer it takes, the more swelling occurs, visualization decreases, and the struggle's on. You need to effectively visualize by clearing out the subacromial space and utilize as many accessory portals as you need to manipulate the soft tissue and to see what you need to see. Don't be afraid to make extra poke-hole incisions in order to see everything you need to on your rotator cuff tear. Once you've repaired the space, next you need to plan your repair. This is the most underutilized and underappreciated part of the rotator cuff repair, particularly in young surgeons. Take two to three minutes to understand your tear. Use a cuff grasper to manipulate the cuff and learn where it belongs. You'd be surprised how many times you'll be fooled. Once you're manipulating the cuff, you're gonna also envision where you'd like to pass your sutures when you go on to your repair. Next, you'll prepare your tuberosity for the repair. You'll want to lightly debride the soft tissues over the bone and lightly decorticate. You want to avoid decorticating in areas where you're gonna place your anchors, particularly if you're using an all-suture suture anchor. This is where the cortex is vital to the strength of that suture anchor. Finally, debride the rotator cuff tendon edges and you're gonna mobilize the cuff. I often will use a blunt rasp above and below the rotator cuff while I'm holding it under tension. Frequently, there'll be adhesions to the glenoid neck immediately just over the superior aspect of the glenoid. And by releasing these adhesions, you're gonna see you're gonna optimize your mobilization of the rotator cuff and minimize the tension of the repair. Next, you'll want to execute your plan. In a double row repair, you're gonna place your medial row anchors first. A spinal needle will help you localize anchor placement. You're gonna hug the acromion and adduct the arm to optimize your angle of anchor placement. I'll typically be in a lateral position for my rotator cuff repair, so I'll gently lean on the elbow to help adduct the arm. This will optimize that angle and try and minimize your chances of penetrating the humeral head. I'll also rotate the arm, both internal and externally, in order to gain access to both the anterior and posterior aspects of the greater tuberosity. I'll place my medial row anchors from anterior to posterior and retrieve them out the anterior cannula as I go to avoid suture traffic. Then when you move on to the suture passing, you're gonna pass these sutures where you previously visualized from the lateral portal. I'll typically pass from posterior to anterior. This avoids suture traffic for me. Be sure to use your cannula and keep it deep to the deltoid fascia or ensure that you're coming in and out of the same tissue plane laterally to avoid a soft tissue bridge. In the suture passing portion of the rotator cuff tear, in my opinion, this is your greatest opportunity to be efficient. You really need to utilize your surgical team. You can use them for retrieving suture, holding the camera, loading a suture passer, cutting sutures, and loading anchors. You're gonna wanna be two steps ahead and give your team directions so they can anticipate the next step and help you be efficient. The final step is to complete your double row construct with your lateral suture anchors. You need to clear the soft tissues laterally and I'll use my bicipital groove as a reference point anteriorly. This is gonna be an area where you're gonna have some of the best bone and typically where I'm gonna put my most anterior suture anticipating this is a more anterior rotator cuff tear. You can simulate your anchor placement by either gathering your suture tails with a tape grasper and holding them with some tension to envision where you would put a lateral row anchor. Or if you have a hard body cannula, you can also hold tension on your suture tails and move your cannula around to anticipate where you'd like to place your lateral row anchors. This is also a time where you need to understand your bone quality. Think back when you did your media row, was the bone soft? If the bone was soft, you may need to under punch or if it was hard, you might need a larger tap or a larger punch and be more line to line. Also, the bone quality needs to be considered when you're tensioning your lateral row. If you over tension and soft bone on your lateral row and you mallet that knotless anchor down, the sutures can cut through the bone and create difficulty with being able to maintain tension on your sutures or the anchor can pull out. Secondarily, this is getting to the end of your case so visualization may start to become an issue. This is where you wanna understand what aids you have available. I'll occasionally have a Gemini cannula available. This will allow me to retract the lateral soft tissues and help me visualize if I'm losing my visualization laterally. By optimizing my visualization, this will speed me up and prevent struggling. What are some of the pitfalls I've learned? It seems like in practice, my attendings all follow the red line that you see in that cartoon there but I managed to jump in each of those holes as I was learning and it's gonna happen and you're gonna start to learn the red path too by learning from mistakes. Trust me, that's how your attendings learned as well. For me, visualization is key. You wanna run the pump low, minimize fascial violation and be as efficient as possible. You can always be working on your efficiency. Soft bone is the enemy so minimize decortication and be ready to upsize anchors. If you're using the Arthrex repair suture in one of their swivel locks laterally, you wanna tension your dog ear repair stitch with a knot pusher while holding counter pressure on the anchor. If you do pull on that repair stitch without counter tension, you can pull the anchor out of the bone and if you've already cut your suture tails before pulling out the anchor, it's a bad day. Ask me how I know. So the second part of this talk will briefly touch on operative management of partial rotator cuff tears. Managing partial rotator cuff tear for me, I'll typically follow the AAOS clinical practice guidelines for the most part in some of the older literature. The width of the supraspinatus footprint is roughly 12 millimeters. So if the tear is less than 50%, literature would suggest that you'd be able to decorticate. So if there's less than seven millimeters of rotator cuff tendon tear, I'll decorticate with a burr or a shaver. And I know the shaver that I use is four millimeters so if that tear is greater than one and a half of my diameter of the shaver, I'm probably gonna be repairing. If it's less than that, I'm going to be debriding or decorticating that area of the tear. I'll also use the spinal needle for tactile feedback. When you push against the rotator cuff tendon, you'll feel resistance from good quality tendon. However, when you have a high grade tear, you're gonna feel that spinal needle fall into that tear very easily. When we look here at the clinical practice guidelines, there's a strong recommendation for transtendinous repair or converting to a full thickness tear and repairing in a high grade partial thickness tear. There are also some that are moving to patch augmentation. And some of the things you have to consider with patch augmentation is definitely the cost and potential fibrosis or inflammatory reaction to the graft. A few pearls when managing a partial thickness tear is to be sure to study your MRI preoperatively to help localize the tear. You can get into that rotator cuff tear and be a little bit lost if you're not knowing where you're gonna be looking. You also wanna assess the cuff from both the articular and the bursal side carefully. If there's any question when looking from the articular side, I'll typically leave a spinal needle in for localization. And then coming from the bursal side, I'll look for that spinal needle and try and assess using my tactile feedback technique. Secondarily, as you can see in this picture here, there's a bump on the bursal side of the supraspinatus that helps define the supraspinatus. This can help orient you when you're in the bursal aspect of the rotator cuff tendons and you're looking for a rotator cuff tendon tear. If you're taking down rotator cuff tendon to do a repair, you wanna preserve as much of the tendon as possible. I'll often trephinate with the spinal needle and or use an elevator to help complete my rotator cuff tendon tear. I try to avoid as much radiofrequency ablation as possible. And then when I get to the repair technique, it's gonna be the double row repair as we have previously discussed in the last slide. Thank you for your.

rotator cuff repair techniques

double row rotator cuff repair

partial tears management

soft tissue control

visualization in rotator cuff repair

double-row rotator cuff repair

indications

techniques

pitfalls

partial rotator cuff tears