Stephen S. Burkhart

The rather turbulent history of arthroscopic rotator cuff repair went through stages of innovation, conflict, disruption, assimilation, and transformation that might be anticipated when a new and advanced technology (arthroscopic cuff repair) displaces an entrenched but outdated discipline (open cuff repair). The transition from open to arthroscopic rotator cuff repair has been a major paradigm shift that has greatly benefited patients. However, this technical evolution/revolution has also imposed a higher "burden of craft" on the practitioners of arthroscopic rotator cuff repair. Technological advancements in surgery demand that surgeons accept this burden of craft and master the advanced technology for the benefit of their patients. This article outlines the author's involvement in the development of arthroscopic rotator cuff repair, and it also explores the surgeon's obligation to accept the burden of craft that is imposed by this discipline.

Purpose: To compare the American Shoulder and Elbow Surgeons (ASES) and the Single Assessment Numerical Evaluation (SANE) scores after rotator cuff repair, rotator cuff revision, and SLAP repair. Methods: This study was a retrospective review of a prospectively filled database of 262 patients who underwent arthroscopic surgery for rotator cuff tears or SLAP lesions between 1999 and 2007. All patients were operated on by the same surgeon, with a minimum follow‐up of 2 years. The patient database included preoperative and outcome measures, such as pain, range of motion, and notably postoperative ASES and SANE scores. Any patient with incomplete data was removed from the study. Results: Three groups were identified: primary rotator cuff repair (n = 135), rotator cuff revision (n = 73), and SLAP repair (n = 54). The overall mean ASES and SANE scores after surgery were 82.7 (± 20.2) and 83.3 (± 19.6), respectively. The Pearson correlation coefficient ( r ) between both scores was 0.8 ( P < .001), demonstrating a very good correlation. In subgroup analysis, the correlation was highest in the cuff revision group ( r = 0.88; P < .001) followed by the SLAP group ( r = 0.78; P < .001) and primary cuff group ( r = 0.75; P < .001). Conclusions: This study shows that there is a significant correlation between postoperative SANE and ASES rating methods in rotator cuff and SLAP repairs. We recommend the SANE score as a reliable outcome indicator for iterative follow‐up, which can then be combined with a more clinically informative score such as the ASES or other process‐based scores for preoperative and final workup. Level of Evidence: Level III, retrospective comparative study.

Our purpose was to determine the relationship between number of preoperative shoulder dislocations and total dislocation time and the need to perform bone deficiency procedures at the time of primary anterior instability surgery. Our hypothesis was that need for bone deficiency procedures would increase with the total number and hours of dislocation. A retrospective review was performed of primary instability surgeries performed by a single surgeon. Patients with 25% glenoid bone loss were treated with Latarjet reconstruction. Number of dislocations and total dislocation time were examined for their relationship with the treatment method. Ten arthroscopic Bankart repairs, 13 arthroscopic Bankart plus remplissage procedures, and 9 Latarjet reconstructions were available for review. Total dislocations (P = 0.012) and total hours of dislocation (P = 0.019) increased from the Bankart, to the remplissage, to the Latarjet groups. Patients with a total dislocation time of 5 h or more were more likely to require a Latarjet reconstruction (P = 0.039). Patients with only 1 preoperative dislocation were treated with an isolated Bankart repair in 64% (7 of 11) of cases, whereas those with 2 or more dislocations required a bone loss procedure in 86% (18 of 21) of cases (P = 0.013). Increasing number of dislocations and total dislocation time are associated with the development of glenoid and humeral head bony lesions that alter surgical management of anterior shoulder instability. The necessity for the addition of a remplissage to an arthroscopic Bankart repair or the use of a Latarjet reconstruction increases with only 1 recurrent dislocation. Level III, retrospective comparative study.

Suture anchors are being increasingly reported as a means of fixation of torn rotator cuff tendons to bone. The author has developed a mechanical model for the suture anchor–rotator cuff construct based on an analogy to the deadman system used to stabilize a corner fence post. Using this model, one can demonstrate a mechanically favorable angle of insertion of the suture anchor (θ ₁ ) such that the anchor's pullout strength is increased at low angles of θ ₁ . In addition, the angle that the suture makes with the direction of pull of the rotator cuff (θ ₂ ) has a direct effect on tension in the suture. A low angle of θ ₂ minimizes the total tension in the suture, thereby minimizing the chance of suture breakage.

For anterior instability with glenoid bone loss comprising 25% or more of the inferior glenoid diameter (inverted‐pear glenoid), the consensus of recent authors is that glenoid bone grafting should be performed. Although the engaging Hill‐Sachs lesion has been recognized as a risk factor for recurrent anterior instability, there has been no generally accepted method for quantifying the Hill‐Sachs lesion and then integrating that quantification into treatment recommendations, taking into account the geometric interplay of various sizes and various orientations of bipolar (humeral‐sided plus glenoid‐sided) bone loss. We have developed a method (both radiographic and arthroscopic) that uses the concept of the glenoid track to determine whether a Hill‐Sachs lesion will engage the anterior glenoid rim, whether or not there is concomitant anterior glenoid bone loss. If the Hill‐Sachs lesion engages, it is called an “off‐track” Hill‐Sachs lesion; if it does not engage, it is an “on‐track” lesion. On the basis of our quantitative method, we have developed a treatment paradigm with specific surgical criteria for all patients with anterior instability, both with and without bipolar bone loss.

Although the subscapularis has historically received less attention than posterosuperior rotator cuff tears, repair of a torn subscapularis tendon is critically important to restoring anatomy and achieving the best functional outcome possible. Arthroscopic repair begins with proper recognition of the tear. A systematic approach can then be used to arthroscopically repair all types of subscapularis tendon tears, from partial tears to full‐thickness tears, as well as those which are retracted and have adhesions medially. Subscapularis footprint restoration can be accomplished with a variety of repair techniques that must be matched to the extent of the tear and mobility of the tendon. Technique Video: video See video under supplementary data.