Arthroscopic technique for patch augmentation of rotator cuff repairs.

The patient is placed in the lateral position, and an arthroscopic cuff repair is performed according to standard techniques. The line of repair is usually in the shape of a "T" or an "L." The repair is viewed through the lateral portal, with fluid inflow through the scope. Mattress sutures are placed in the anterior and posterior portions of the cuff, with respect to the line of repair, just medial to the most medial point of the tear. The sutures are placed in accordance with margin convergence suture passing methods. Next, 2 double-stranded suture anchors are placed into the lateral aspect of the greater tuberosity, which can be used to secure the anterior and posterior portions of the rotator cuff as well as the patch. The cuff sutures are tied first; then, the patch is addressed. The graft is sized by placement of a ruled probe or similar device into the subacromial space. The length of each side of the "rectangle" is measured to obtain the dimensions of the patch. The patch is then cut to fit the measurements. If the patch material is elastic, a slightly smaller than measured graft is cut to provide tension on the repair. The arthroscope is then moved to the posterior portal, and a large (8 mm) cannula, with a dam, is placed into the lateral portal. All sutures are brought out of the lateral cannula, and corresponding ends of each suture are held together in a clamp. The sutures are placed in their respective orientations once outside the cannula (e.g., anterior-medial, anterior-lateral), covering all 4 quadrants. Care is taken to ensure that the sutures have no twists and are not wrapped around one another. The sutures are passed through the graft, in mattress fashion, with a free needle, in their respective corners and clamped again. The graft is then grasped with a small locking grasper on its medial edge and is passed through the cannula into the subacromial space. The clamps holding the sutures are then gently pulled to remove the slack. A smaller (5 mm) cannula is placed through 1 of the anchor incisions into the subacromial space. The medial 2 sutures are retrieved, a pair at a time, through the small cannula and are tied according to standard arthroscopic techniques; then, the lateral 2 sutures are retrieved from the anchor. The graft should cover the area of repair completely and should be under slight tension. Additional sutures may be placed to further secure or tension the graft as necessary, with the use of standard suture passing techniques, similar to those used when margin convergence is performed. Passive shoulder motion, pendulum exercises, and active elbow and wrist motion begin 2 days after surgery when the dressing is removed. Active assisted motion and active motion begin at 6 weeks, with integrated periscapular stabilization exercises. Formal cuff strengthening begins no sooner than 12 weeks after surgery for large and massive tears.