SHOULDER ARTHROSCOPY AND ARTHROSCOPIC
Shoulder Arthroscopy and Arthroscopic
Lanny Johnson, the father of shoulder
arthroscopy, stated twenty years ago that
any operation on the shoulder joint itself
or on the tissues nearby should be preceded
by or combined with an arthroscopic
examination. This statement was highly
controversial at that time when it was made
but is true today. Shoulder arthroscopy has
evolved over the last 2 decades and most of
the soft tissue problems in and around the
shoulder can be treated successfully with
arthroscopy, the results being equivalent or
superior to that of the open procedure.
The following are common arthroscopic
procedures done in the shoulder:
Sub acromial Decompression (Bursectomy +
Resection of Lateral end of clavicle.
Removal of Calcific Deposits in the cuff.
Rotator cuff repairs.
Bankart repair and Bankart shift.
Plication of the Capsule.
Suprascapular nerve release.
Brachial plexus catheter placement for
post OP pain control.
ROTATOR CUFF TEARS - The MIOT Approach
Rotator Cuff tears may be degenerative or
traumatic. In both categories a strong
association of Type 3 acromion as well as
osteophytes along the inferior aspect of the
acromioclavicular joint has been reported.
A rotator cuff tear can manifest clinically
as mild shoulder pain to complete loss of
function in the shoulder. Night pains and
sleep disturbances are very common. It can
be diagnosed by various clinical tests
described for each and every muscle in the
cuff crescent. For supraspinatus 0o
Abduction strength test, For InfraSpinatus
and Teres minor - dropping arm test and Horn
Blower’s test, for subscapularis - belly
press test and lift-off test. The cuff tears
can be confirmed with an MRI / MR arthogram
Once a cuff tear is confirmed it needs
intervention. Arthroscopic rotator cuff
repair is the preferred approach in our
institute. It avoids the compromise of the
deltoid origin seen in the conventional open
approach or a difficult retraction of the
deltoid fibers seen in the Mini - Open
repair. Before an intervention is decided,
one should be aware of an entity - the
irreparable rotator cuff tear. This is
revealed by the following:
In these cases, rest of the cuff tears
should be advised. Once a thorough 15 point
Glenohumeral diagnostic arthroscopy (SNYDER)
is completed, a quick subacromial
decompression (SAD) has to be performed
otherwise a tense swelling in the shoulder
makes an arthroscopic repair difficult. Once
the SAD is over, the first step is to asses
the nature of the cuff tear using various
I. Based on the thickness of the cuff
Complete tear requires repair as well as
partial thickness tears involving more than
50% thickness of the cuff with cuff symptoms
and non degenerative tears with less
inflammation in the bursa. Other partial
tears can be debrided and left alone.
II. Based on the Shape of the tear
L - Shaped.
U - Shaped.
Assessment of tear configuration is very
important to decide the type of repair.
III. Based on the Retraction of the
Grade I - Torn without significant
Grade II - Torn and retracted up to mid
head of humerus.
Grade III - Retracted to the gleonoid
The greater the retraction, higher the
chances that the cuff substance is adherent
to the surrounding structures and most
likely a release should be performed.
IV. Based on the tendon which it involves
V. Based on the Size
The size conformation helps to decide a
single row repair or a double row repair and
also the number of suture anchors to be
Once the nature of the tear is assessed then
the cuff mobility is checked. The torn cuff
tendons must be reattached to a mechanically
favorable site on the bone bed without undue
tension on the repair. A tension free repair
is essential for successful healing of the
tendon. The most important pre requisite for
healing of a biologically repaired tissue is
the structural integrity of the entire
construct. A loose suture or poorly placed
anchor can mean loss of integrity of the
The suture anchor must be placed at an angle
of 45o to the bone (Deadman angle), so it
can resist the pullout forces to the
maximum. Loop security and knot security are
important. Each suture (Non absorbable
Ethibond & etc.) can resist a load of 35-40
N with the entire knot configuration except
the one which has all the half hitches
thrown in the same direction. We use the
sliding hangman knot followed by half
hitches in different directions and
alternately changing the post. When a large
tear is repaired, at least 6 fixation points
(leaving the two existing fixation points –
either ends of the cuff tear) are required.
This means at least 3 suture anchors each
with two sutures will be needed for the
repair of the large tears.
We prefer to use double row repair technique
in all the tears except small tears. Single
row repair reattaches the tendon to the
outer margin of the foot print. This may
cause a windshield wiper effect between the
cuff and the tuberosity. This shear force
may hamper healing. A double row repair puts
the whole cuff tendon under compression and
increases the contact area over the bone.
This creates a favorable environment for the
healing of the tendon. The inner row anchors
are placed at the juxta artcular margin and
the outer row anchors at the summit of the
greater tuberosity. One should be careful
not to remove the cortical bone over the
tuberosity. Preparation should stop at the
level of bleeding bone.
Once the suture anchor is placed, suture
capture of the tendon is performed with the
help of any one of the instruments (eg.
Suture hooks, Tissue penetrators, Scorpio,
etc). The inner row sutures are passed at
the musculo tendinous junction and the outer
row sutures are passed 5-10mm from the free
margin of the cuff. We prefer mattress
suture for inner row and simple or lasso
loop stitch for the outer row.
Suture entanglement and inadvertent pulling
of the suture out of the anchor must be
avoided. Twists must be removed before the
knot is tightened. The slack between the
half hitches must be removed by past
pointing every time.
Crescent shaped tears are directly
reattached to the bone bed. But an ‘L’
shaped tear repair first starts at the
corner reattachment. Then the vertical limb
is approximated (Marginal convergence)
leaving the knots over the posterior leaf to
avoid suture impingement. Finally, the
horizontal limb is reattached to the bone
bed, using suture anchors. The same
technique is used for the repair of ‘U’
shaped tears. The vertical limb is
approximated first (Marginal Convergence)
following by reattachment of the horizontal
limb to the bone bed by suture anchors.
When the tendon is not freely mobile, a
release technique is performed, -
peri-tendinous and peri-glenoid releases are
done first. If it is still not mobile, then
the interval slide is performed.
When the tear involves the attachment of the
coracohumeral ligament, it retracts back to
the coracoid process taking the cuff tendon
along with it. Without releasing the
coracohumeral ligament from the cuff or from
the coracoid process it may not be possible
to reattach the tendon to the desired place.
The release of the coracohumeral ligament is
achevied with the Interval slide done at the
level of the rotator interval.
When a ‘U’ shaped tear involves
infraspiratus the posterior leaf has to be
proximalised and even when a complete repair
is not possible and part of the superior
surface of the head is visible one should
continue to do a partial repair to balance
the force couples between the anterior
fibers and the posterior fibers. This
balance helps the shoulder joint to
establish a stable fulcrum of glenohumeral
motion. Without understanding shoulder
mechanics, trying to cover a rent in the
cuff may make the shoulder worse.
Rehabilitation Protocol : There are four
Phase I : (0-6 weeks)
Patient is protected with a shoulder
immobilizer when they are not doing the
exercises particularly at night. During this
period active elbow motion exercises and
grip strengthening are allowed. Passive
shoulder mobilization exercises are started
and based on the nature of the tear and the
stability of the repair we allow upto 120o
forward elevation and 20o external rotation.
Phase II : (Is from 6-12 weeks)
Sling is discarded. Full possible motion,
active assisted exercises are started and
then we progress to active motion exercise.
Phase III : (From 12-16 weeks)
Strengthening exercise and stretching
exercise to get a full range of movement are
advised at this stage.
Phase IV : (After 16 weeks)
Once original strength is regained, patients
can return to labour intensive occupations
and sporting activities.