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Arthroscopic Rotator Cuff Repair

- Discussion:
      - rotator cuff anatomy
- etiology of RTC tears
how do these tears heal?
- massive RTC
- open rotator cuff repair

- Technique:
    - arthroscopy exposure and setup
            - inorder to avoid extrasavation, begin with fluid pressure at 35 mm, and increased pressures incrementally as necessary;
    - irrigation fluid management
    - visualization:
- manipulation:
consider manipulation into full flexion and abduction prior to prepping to help stretch the posterior capsule;
- anterolateral traction will impove the viewing area, and facilitate procedure;
- posterior portal: consider placing this slightly more lateral to facilitate visualization;
- consider slightly shifting porotals inferior since portals will migrate superiorly with shoulder infiltration and swelling;
- allows better triangulation (than lateral portal) for approach to supraspinatus;
- references:
- Subacromial internal spacer for rotator cuff tendon repair: "the balloon technique".
- A Simple Way to Improve Visualization and Increase Working Space in Arthroscopy: The Pull-String Technique
- The Accessory Posteromedial Portal Revisited: Utility for Arthroscopic Rotator Cuff Repair

- Surgical Considerations:
        - biceps tendon and slap tear
      - subacromial bursectomy
        - cuff debridement:
- Apoptosis Occurs Throughout the Diseased Rotator Cuff
                         - Rotator Cuff Tear Degeneration and Cell Apoptosis in Smokers Versus Nonsmokers
       - arthroscopic acromioplasty
- question need for acromioplasty with RTC repair;
        - distal clavicle excision
- references:
- Asymptomatic AC joint arthritis in arthroscopic rotator cuff tendon repair: a prospective randomized comparison study.
- Is arthroscopic distal clavicle resection necessary for patients with radiological acromioclavicular joint arthritis and rotator cuff tears? A prospective randomized comparative study.
                    - Arthroscopic distal clavicle resection in symptomatic acromioclavicular joint arthritis combined with rotator cuff tear: a prospective randomized trial.

        - capsular release for stiffness:
- Are delayed operations effective for patients with rotator cuff tears and concomitant stiffness? An analysis of immediate versus delayed surgery on outcomes.
- Clinical outcomes of rotator cuff repair with arthroscopic capsular release and manipulation for rotator cuff tear with stiffness: a matched-pair comparative study between patients with and without stiffness.

- Cuff Repair Techniques
       - surgical goals:
- restoration of anatomy (with no lateralization of repair and no unnecessary increase in tension of the repair);
- any lateralization of cuff repair may cause excessive tension (increase failure) and may end up minimizing compresssion
against the foot print;
- goal should be restoration of the footprint with the end of the cuff placed under compression against the bleeding footprint;
- suture and anchor placement should function to compress cuff against footprint, and to work to prevent cuff lateralization;
- required steps:
             1) assessment of cuff tear
2) cuff mobilization (convergence repair)
3) preparation and restoration of  the foot print
4) core tendon repair techniques:
                     - double row and single row techniques:
- core flexor tendon repair techniques: dont forget the contributions of the hand sugeons to tendon repair;
- remember that the main cause of rotator cuff repair failure is when the suture pulls through the tendon;
- references:
- Mode of failure for rotator cuff repair with suture anchors identified at revision surgery.
- Medial Versus Lateral Supraspinatus Tendon Properties. Implications for Double-Row Rotator Cuff Repair
- An arthroscopic stitch for massive rotator cuff tears: the Mac stitch
- Biomechanical evaluation of arthroscopic rotator cuff stitches.
             5) bone anchor insertion
- this step takes into consideration restoration of footprint and optimally making sure that tensioned cuff is draped over
anchor site;
             7) tensioning and locking of sutures
- sutures can be locked to anchor vs. knot tying tech
8) biologic measures: microfracture / PRP
- PRP for arthroscopic repair of large to massive rotator cuff tears: a randomized, single-blind, parallel-group trial.

- Phyiscal Therapy after RTC Repair

- Post Operative Milestones:
Temporal Evolution of MRI Findings After Arthroscopic Rotator Cuff Repair

- Complications:
      - Incidence and treatment of postoperative stiffness following arthroscopic rotator cuff repair.
- Upper Airway Compromise by Extravasated Fluid: A Rare Complication After Arthroscopic Repair of Atrophic Cuff Tear
- The Long-Term Outcome of Recurrent Defects After Rotator Cuff Repair.


Pearls and pitfalls: Arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair using a tension band suture technique

Open, Mini-open, and All-Arthroscopic Rotator Cuff Repair Surgery: Indications and Implications for Rehabilitation

Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness?

Repair Integrity and Functional Outcomes After Arthroscopic Suture-Bridge Rotator Cuff Repair