Rotator Cuff Repair and Shoulder Instability Surgery

Arthroscopic rotator cuff repair now ranges from single-row and double-row repairs to patch augmentation, in which a synthetic patch reinforces a poor-quality or massive tear, with superior capsular reconstruction, tendon transfer or reverse shoulder replacement reserved for irreparable tears. For a dislocating shoulder, the operation is chosen by bone loss: a Bankart repair, a Bankart repair with remplissage, or a Latarjet procedure.

Dr. Vipin Maheshwari, Sr. Consultant - Orthopaedics, Artemis Hospitals, Gurugram, India, calls shoulder arthroscopy one of the favourite operations of many surgeons. His approach to both of its main problems, the torn rotator cuff and the unstable shoulder, rests on the same discipline: match the operation to the tissue, the bone and the patient's demands. This article sets out his decision-making for each. The complete guide to knee and shoulder arthroscopy gives the overview, and the ACL reconstruction article shows how the same synthetic materials are used in the knee.

Why rotator cuff tears are increasingly common

The rotator cuff is a group of four tendons (supraspinatus, infraspinatus, subscapularis and teres minor) that wrap the ball of the shoulder and both move and stabilise it. Tears are increasingly prevalent as people live longer and stay active into later life, and they arise mainly from degeneration: the end of the tendon has a poor blood supply, and over the years it frays and tears.

That same poor blood supply means rotator cuff tears do not repair themselves well. It also explains why so much recent progress lies in improving the biology of the repair, not only its mechanics.

How rotator cuff repair has evolved

Dr. Maheshwari traced four generations of repair:

1. Single-row repair. The torn tendon, usually the supraspinatus, is grasped with a few suture bites and fixed back onto the greater tuberosity, the bony prominence where it attaches.
2. Double-row and suture bridge repair. A medial and a lateral row of anchors spread the tendon over a wider footprint of bone, improving contact and healing.
3. Rip-stop constructs, which reinforce the stitch so it is less likely to pull through weak tendon.
4. Patch augmentation, the newest step, for tendons whose quality cannot be trusted.

In one case he showed, an old, complete tear of the supraspinatus and infraspinatus was mobilised, the bone of the tuberosity was prepared, and a double-row repair brought the tendon back over its footprint with medial and lateral rows of sutures; platelet-rich plasma (PRP), a platelet concentrate from the patient's blood, was added once the construct was complete.

Patch augmentation: when the tendon cannot carry the repair alone

A patch is a sheet of synthetic material, the same material as some synthetic ACL grafts, laid over the repaired tendon arthroscopically, sutured to it and fixed laterally to bone. It shares the load while the tendon heals.

Dr. Maheshwari considers a patch when:

• The patient presents late, six months to a year after the tear, with a retracted tendon of inadequate quality and fatty atrophy, the replacement of muscle by fat that follows a long-standing tear.
• The tear is massive, involving the supraspinatus, infraspinatus and subscapularis, so that suture anchors alone cannot be relied upon.
• Bone quality is poor, so that adding more and more anchors is not an answer.
• The operation is a revision. Here the tendon has already shown that its quality is poor, which is why it tore again; in revision surgery he always adds a patch.

Biological augmentation of the repair

Because a poor blood supply limits healing, surgeons now try to recreate the biology at the repair site. Options include PRP, bone marrow aspirate concentrate (BMAC), bioinductive collagen implants and dermal allografts. Some surgeons use the long head of biceps tendon or the subacromial bursa as local tissue. Dr. Maheshwari's own preference is orthobiologics, adding PRP and BMAC to the repair, which in his view help revascularise the graft.

The irreparable rotator cuff tear: a decision ladder

Dr. Maheshwari's sequence for rotator cuff surgery is simple to state:

1. If the tendon is repairable, repair it.
2. If the tissue is poor, repair it and add a patch.
3. If the tendon will not come back to the bone, consider superior capsular reconstruction or a tendon transfer.
4. If the tear is irreparable and arthritis has already set in, proceed to reverse shoulder arthroplasty, a shoulder replacement in which the ball and socket are reversed so that the deltoid muscle can power the arm without a functioning cuff.

Superior capsular reconstruction

Superior capsular reconstruction (SCR) suits a patient whose rotator cuff cannot be brought back and who does not want a tendon transfer, which is a bigger operation. Anchors are placed in the upper glenoid (the socket of the shoulder) and the greater tuberosity, and a graft is fixed between them to recreate the superior restraint the supraspinatus once provided, keeping the ball of the humerus centred. The graft can be the patient's own fascia lata, from the outer thigh, or one of the allografts now available.

The alternative, a tendon transfer, moves a healthy neighbouring tendon to take over the work of the irreparable one. It is the larger operation, which is why SCR appeals to patients who want to avoid it.

Shoulder instability surgery: Bankart repair, remplissage or Latarjet?

The right operation for an unstable shoulder depends on how much bone has been lost from the glenoid and whether the Hill-Sachs lesion engages: Dr. Maheshwari uses a Bankart repair below 17% glenoid bone loss, adds remplissage for an off-track or large Hill-Sachs lesion, and advocates the Latarjet procedure above 17%.

Shoulder dislocations are becoming more common, driven by contact sports such as boxing and taekwondo, in which abnormal forces push the ball of the shoulder out of its socket. Patients typically return when the shoulder has started to come out frequently and want it fixed.

Dr. Maheshwari's central point is that not every instability needs only a Bankart repair. Before choosing, he assesses:

• the clinical examination;
• how old the injury is;
• how much bone has been lost from the glenoid;
• how the humeral head tracks on the glenoid, and whether the Hill-Sachs lesion engages.

A Hill-Sachs lesion is a dent in the back of the humeral head caused when it is driven against the rim of the glenoid during dislocation. In the glenoid track concept, a lesion that stays within the contact area of the glenoid as the arm moves is "on-track"; one that extends beyond it can catch on the glenoid rim, or engage, and is "off-track", which makes recurrence more likely.

Bankart repair

The Bankart lesion is a tear of the labrum, the ring of cartilage that deepens the socket, together with the anterior capsule from the front of the glenoid. In a Bankart repair, anchors are placed in the glenoid and the anterior capsule and labrum are brought back onto its surface, restoring the bumper at the front of the socket. Dr. Maheshwari uses it for a tear with glenoid bone loss below 17%.

Remplissage

Remplissage (French for "filling") addresses a large or engaging Hill-Sachs lesion. Anchors are placed into the defect on the back of the humeral head, and their sutures are passed through the posterior capsule and infraspinatus tendon, which are then tightened into the defect. The defect is filled with soft tissue so it can no longer engage. Dr. Maheshwari adds remplissage to the Bankart repair for an off-track, engaging lesion or a large Hill-Sachs lesion.

The Latarjet procedure

When bone loss is too great for soft tissue repair, a Bankart repair will fail, and Dr. Maheshwari advises against even attempting one. The answer is a bony reconstruction: the Latarjet procedure, in which the coracoid process with its attached tendons is transferred to the front of the glenoid. It restores the bone and adds a sling effect, a dynamic stabilisation, as the transferred tendons support the front of the joint when the arm is raised and rotated outwards.

His thresholds and preferences:

• Glenoid bone loss above 17%: he advocates the Latarjet procedure.
• A failed Bankart repair with continuing instability: consider a Latarjet.
• Technique: some surgeons perform the Latarjet arthroscopically; in his experience it works better as an open operation, which is its only real disadvantage.
• Without significant bone loss, a failed repair can be addressed with another labral repair.

"Remember," he told the audience, "it is the bone loss that dictates this procedure."

Matching the operation to the patient

Personalisation runs through his instability practice. Most patients who come to his clinic with a dislocating shoulder are not athletes who have dislocated many times, and they do not need the most demanding stabilisation. Every patient's MRI and CT scans should drive the plan, and the operation should fit their anatomy and their demands.

Protecting the shoulder in the gym

Prevention matters as much as repair. In fly exercises, Dr. Maheshwari advises against taking the arms too far back, especially for anyone with a history of subluxation (partial dislocation) or shoulder pain. Pain during an exercise is a signal to stop, rest and restart later at a lower weight. The complete guide lists the other gym exercises he considers most dangerous.

Success rates and cost of shoulder arthroscopy

Dr. Maheshwari put the success rate of well-planned surgery for a dislocating shoulder at about 95 to 98%, and of rotator cuff repair at about 90 to 95%, defining success as a return to the patient's condition before the injury. He attributes these results to recreating the biology and to advances in implants. Published series set a more conservative benchmark: recurrence after arthroscopic Bankart repair is commonly about 10 to 20%, higher in young contact athletes, and around one rotator cuff repair in four re-tears, more often in large and massive tears, although most patients still gain good pain relief and function.

He gave an approximate all-inclusive cost at Artemis Hospitals of USD 4,000 to 5,000 for a simple Bankart repair using about three anchors, with remplissage adding about USD 1,000. He noted that shoulder procedures use only small anchors, and that most single procedures in either joint fall between USD 4,000 and 5,000. Benchmarks for other arthroscopic procedures are on the orthopaedic treatment cost page, and the questions doctors asked in the session are answered in the Live Discussion. For other bone and joint specialists in the network, see the orthopaedics specialty hub.