Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Small Tears Less Than 1 Centimeter

Smaller tears are easily missed as patients present with findings and symptoms consistent with impingement. Occasionally weakness is present, but even following the Neer test, significant weakness may not be detected.

These tears usually involve the supraspinatus tendon insertion, and pain is the primary presenting complaint. Examination usually reveals normal motion and strength.

After the diagnosis has been confirmed, usually by MR testing, definitive treatment can be individualized. Several authors have shown that small tears treated with decompression alone can achieve significant pain relief while maintaining good function . In an older patient unable or unwilling to undergo the more arduous rehabilitation associated with a full thickness repair, the simple decompression alternative is a realistic one. In the younger, more active population, obvious concern regarding propagation of the tear is a legitimate one.

The study by Yamaguchi et al. It reveals a 51% incidence of asymptomatic to symptomatic tearing over a five-year period raises doubts about a simple decompression resulting in a lasting and durable outcome for those who lead a vigorous lifestyle. For those individuals, a decompression in conjunction with a repair is the treatment of choice.

Although the open acromioplasty and rotator cuff repair technique has been associated with a high success rate, the technique has been supplanted by the arthroscopically assisted mini-open and the all-arthroscopic techniques. Several studies have validated these two newer approaches with success rates equal to those achieved through an incision alone . Furthermore, the mini-open and all-arthroscopic techniques have demonstrated little or no difference when compared in clinical studies.

The all-arthroscopic approach relies on meticulous technique and a well-patterned step-wise approach to a successful outcome. Arthroscopy is particularly helpful in allowing a panoramic view of the torn rotator cuff. After the tear pattern is recognized, an anatomic repair can be achieved. The goal of rotator cuff surgery is to achieve an anatomic repair in which the tendon is stressed appropriately and can function as originally intended.

Using standard anterior, posterior, and lateral portals, the tear is identified and the tear pattern recognized . Small tears are generally crescentic in nature with minimal retraction due to their small size. Associated pathology is identified such as biceps fraying or tearing, and treated. A subacromial decompression is accomplished if there are findings of impingement such as coracoacromial ligament fraying.

The actual rotator cuff repair begins with mobilization of the cuff, if necessary, and using a grasper to reapproximate the torn edge of the cuff back to the greater tuberosity. Simply mobilizing the cuff tendon in larger, retracted tears from a medial to lateral position and re-attaching to bone is usually an oversimplified approach and one that usually leads to structural failure. Chronic tears often have a specific pattern of retraction, and diagonal reduction maneuvers recreate the original anatomic attachment.

The bony bed of the greater tuberosity can be prepared with the shaver blade or a curette in an attempt to minimize bone loss and to maximize the pullout strength of the implants. The suture anchors are placed 5 to 7 mm from the articular margin and are separated by at least 1 cm . The insertion angle approximates 45 degrees from the long axis of the humerus to maximize pull-out characteristics .

There exists a multitude of implant devices intended for rotator cuff repair, and for all, satisfactory bone purchase is essential. After the anchors are inserted, the sutures must be either ante- or retrograded through the free edge of the torn tendon. Numerous ingenious instruments and devices are available to assist the surgeon in accomplishing this portion of the procedure. Several accessory portals are also available which can facilitate retrograde suturing of the rotator cuff.

After the sutures have been passed, careful, meticulous knot-tying is required during which both knot and loop security must be maintained, loop security referring to the tension with the suture itself as it passes through tissue. The final result should consist of an anatomic repair with excellent coaptation of tissue to the bony bed. As the shoulder is ranged, no undue tension on the repair site should be present. Satisfactory clearance in the subacromial space should be verified as well.

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