Surgical Technique for Rotator Cuff Tears

The tendons of the rotator cuff can be repaired either as an “open” technique or an arthroscopic technique, often referred to as “key-hole” surgery.

My preference is for arthroscopic techniques for all repairs, small or large.

With this technique, the entire procedure is performed through 2-3 small nicks in your skin of 6mm to 8mm, referred to as portals.

The portal in the back of the shoulder is used to visualize the shoulder joint, the rotator cuff tear and the subacromial bursa, using an instrument known as an arthroscope. It which contains a fiber-optic tube attached to a miniaturized video camera and the inside of the shoulder is visible to the surgeon on a computer screen.

Two side (lateral) portals are used to insert stitches and “anchors” to pair the torn rotator cuff tendons.

The arthroscopic repair can be performed by two different techniques, single and double row repairs. The attachment site of the supraspinatus tendon is very broad (shaded area). To reproduce this large area of contact between tendon and bone (the footprint), I believe it is preferable where possible to fix the tendon at both sides, the inside (medial) and the outside (lateral). It is likened to fixing a load such as a container onto a semitrailer. You fix one side of the load, and then ratchet down the other side. In some circumstances it is not possible to achieve a double row repair, such as very large and retracted tears. Small tears which are only partially detached don’t need a medial row.

Positioning

The patient is placed on their side and is supported by a bean bag to stabilize their body. The anesthetist will frequently make sure you are comfortable in this position before being anesthetized (put to sleep).

The patient is placed on their side and is supported by a bean bag to stabilize their body. The anaesthetist will frequently make sure you are comfortable in this position before being anaesthetized (put to sleep).

An examination and possible manipulation under anaesthetic is performed to eliminate any stiffness in the shoulder prior to the procedure.

Inserting stitches into the tendon

With the use of specialized instruments we are able to pass sutures through the tendon via an incision less than a centimetre long. The stitches are inserted using an instrument which contains a suture cartridge. The jaw at the end of this instrument closes on the torn end of the tendon by pulling the silver handle holding the tendon gently in place. The instrument passes a needle thru the tendon and pulls the suture through, much like a sewing machine. Once the suture is passed through the tendon, the sutures are retrieved out of the portal.

Fixing the Stitches to the Bone Using Anchors

The suture can then be attached to an anchor. A tiny drill hole (<3mm) is placed in the bone. The anchor with its attached suture is placed in the bone and locked into position. With the anchors in place, the sutures can be tightened. When adequate compression of the tendon onto the bone has been achieved the suture can be locked in position.